| Doctor Name: | KATIE JENDRISAK |
| NPI Number: | 1023365111 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | REGISTERED MHC INTER |
| License Number: | IMH 8503 |
| Business Practice Address: | 160 N Beach St Daytona Beach, FL - 321143314 |
| Business Phone Number: | 3869444707 |
| Business Fax Number: | |
| Mailing Address: | 160 N Beach St, DAYTONA BEACH |
| State: | FL |
| Postal Code: | 321143314 |
| Phone Number: | |
| Fax Number: | |
| NPI Enumeration Date: | 08/08/2012 |
| NPI Last Update Date: | 08/08/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YM0800X |
| License Number: | IMH 8503 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | FL |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Mental Health |
| Taxonomy Definition: | |