Provider Demographics
NPI:1427802867
Name:AHEARN, JENNIFER JANE (MS)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JANE
Last Name:AHEARN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 BRIAN DR
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-2634
Mailing Address - Country:US
Mailing Address - Phone:321-349-6562
Mailing Address - Fax:
Practice Address - Street 1:1600 W EAU GALLIE BLVD STE 201V
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-4149
Practice Address - Country:US
Practice Address - Phone:321-349-6562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-12
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21538101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health