Provider Demographics
NPI:1003104712
Name:TITUS, JENNIFER LYLES (DO)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LYLES
Last Name:TITUS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 MEETING HOUSE LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11968-5009
Mailing Address - Country:US
Mailing Address - Phone:631-726-0409
Mailing Address - Fax:
Practice Address - Street 1:435 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-2805
Practice Address - Country:US
Practice Address - Phone:949-375-1857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-14
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY'STUDENT'207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine