Provider Demographics
NPI:1356622781
Name:JEAN, ANGE-FENNIE
Entity type:Individual
Prefix:
First Name:ANGE-FENNIE
Middle Name:
Last Name:JEAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1454 AVON LN APT 21
Mailing Address - Street 2:
Mailing Address - City:NORTH LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33068-5780
Mailing Address - Country:US
Mailing Address - Phone:786-447-2139
Mailing Address - Fax:
Practice Address - Street 1:14645 NW 77TH AVE STE 101
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33014-2569
Practice Address - Country:US
Practice Address - Phone:833-769-3524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-30
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLMT4454106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program