Provider Demographics
NPI:1386942365
Name:NEWSTROM, JENNIFER LYN
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYN
Last Name:NEWSTROM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYN
Other - Last Name:COLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8100 OPPORTUNITY DR STE B
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32583-8727
Mailing Address - Country:US
Mailing Address - Phone:850-723-6570
Mailing Address - Fax:
Practice Address - Street 1:8100 OPPORTUNITY DR # B
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32583-8727
Practice Address - Country:US
Practice Address - Phone:850-723-6570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-01
Last Update Date:2024-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-24-78668103K00000X
FL0-14-4070103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst