Provider Demographics
NPI:1114385887
Name:MANDER, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MANDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 N PARK ST
Mailing Address - Street 2:
Mailing Address - City:SENECA FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:13148-1437
Mailing Address - Country:US
Mailing Address - Phone:315-568-9412
Mailing Address - Fax:
Practice Address - Street 1:100 WASHINGTON ST
Practice Address - Street 2:ELMIRA PSYCHIATRIC CENTER
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14901-2898
Practice Address - Country:US
Practice Address - Phone:607-737-4711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-09
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNYCPS-P-413175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist