Provider Demographics
NPI:1982925103
Name:DETTLOFF, JENNIFER LYNN (MD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LYNN
Last Name:DETTLOFF
Suffix:
Gender:F
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:14275 MIDWAY RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-3614
Mailing Address - Country:US
Mailing Address - Phone:813-972-7100
Mailing Address - Fax:610-271-4245
Practice Address - Street 1:4225 E FOWLER AVE
Practice Address - Street 2:SUITE B
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33617-2026
Practice Address - Country:US
Practice Address - Phone:813-972-7100
Practice Address - Fax:813-972-8269
Is Sole Proprietor?:No
Enumeration Date:2010-06-22
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL125058726207ZP0102X
FLME127025207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIR179ZMedicare PIN