Provider Demographics
NPI:1033184627
Name:OVERHOLT, JAYNE C (PNP)
Entity Type:Individual
Prefix:
First Name:JAYNE
Middle Name:C
Last Name:OVERHOLT
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5290 MILITARY RD
Mailing Address - Street 2:SUITE #3
Mailing Address - City:LEWISTON
Mailing Address - State:NY
Mailing Address - Zip Code:14092-1953
Mailing Address - Country:US
Mailing Address - Phone:716-297-0052
Mailing Address - Fax:716-297-4530
Practice Address - Street 1:5290 MILITARY RD
Practice Address - Street 2:SUITE #3
Practice Address - City:LEWISTON
Practice Address - State:NY
Practice Address - Zip Code:14092-1953
Practice Address - Country:US
Practice Address - Phone:716-297-0052
Practice Address - Fax:716-297-4530
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF3809201363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY07152689Medicaid