Provider Demographics
NPI:1013411388
Name:KENITZ, JACQUELINE SIERRA (DO)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:SIERRA
Last Name:KENITZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:SIERRA
Other - Last Name:COPPOLA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:47 NEW SCOTLAND AVE DEPT OF
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-3412
Mailing Address - Country:US
Mailing Address - Phone:518-262-5377
Mailing Address - Fax:
Practice Address - Street 1:47 NEW SCOTLAND AVE DEPT OF
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3412
Practice Address - Country:US
Practice Address - Phone:518-262-5377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-21
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY499608657390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program