Provider Demographics
NPI:1063492569
Name:SAMPSON, JENNIFER LYNN (OTR/L, CHT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:SAMPSON
Suffix:
Gender:F
Credentials:OTR/L, CHT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:KOWALCZYK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L, CHT
Mailing Address - Street 1:3923 LAUREL CT
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11783-2643
Mailing Address - Country:US
Mailing Address - Phone:917-543-8136
Mailing Address - Fax:
Practice Address - Street 1:2108 MERRICK MALL
Practice Address - Street 2:
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-3626
Practice Address - Country:US
Practice Address - Phone:516-868-5302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009647174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQT9181Medicare ID - Type Unspecified