Provider Demographics
NPI:1033473558
Name:CARLSON, JEANINE (MSED)
Entity Type:Individual
Prefix:MRS
First Name:JEANINE
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 OAKDALE ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10308-2603
Mailing Address - Country:US
Mailing Address - Phone:718-967-2242
Mailing Address - Fax:
Practice Address - Street 1:79 OAKDALE ST
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10308-2603
Practice Address - Country:US
Practice Address - Phone:718-967-2242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-28
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist