Provider Demographics
NPI:1053687715
Name:DALLINGA, JENNA RUSSELL (LMT)
Entity Type:Individual
Prefix:MS
First Name:JENNA
Middle Name:RUSSELL
Last Name:DALLINGA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 HARVEST DR
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:NY
Mailing Address - Zip Code:10509-3706
Mailing Address - Country:US
Mailing Address - Phone:845-612-9849
Mailing Address - Fax:
Practice Address - Street 1:40 LAKE AVENUE EXT
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06811-5283
Practice Address - Country:US
Practice Address - Phone:845-612-9849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-27
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005456174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist