Provider Demographics
NPI:1609392612
Name:MALLOY, JENNIFER AIDE (LAC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:AIDE
Last Name:MALLOY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2247 PALM BEACH LAKES BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33409-3408
Mailing Address - Country:US
Mailing Address - Phone:561-221-0312
Mailing Address - Fax:
Practice Address - Street 1:2247 PALM BEACH LAKES BLVD STE 105
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33409-3408
Practice Address - Country:US
Practice Address - Phone:561-221-0312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-21
Last Update Date:2024-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP3816171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist