1699079707 NPI number — MR. JEFFREY GLEN PARDONNER LMFT

Table of content: MR. JEFFREY GLEN PARDONNER LMFT (NPI 1699079707)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699079707 NPI number — MR. JEFFREY GLEN PARDONNER LMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PARDONNER
Provider First Name:
JEFFREY
Provider Middle Name:
GLEN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LMFT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699079707
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/04/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2828 LIDO BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GULF BREEZE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32563-3090
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-916-1244
Provider Business Mailing Address Fax Number:
850-916-1244

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
348 MIRACLE STRIP PKWY SW
Provider Second Line Business Practice Location Address:
SUITE B3
Provider Business Practice Location Address City Name:
FORT WALTON BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32548-5200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-862-3772
Provider Business Practice Location Address Fax Number:
850-863-4574
Provider Enumeration Date:
01/04/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  MT 2541 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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