Provider Demographics
NPI:1114964350
Name:DYL, JENNIFER L (PHD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:DYL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 SMITH AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:GREENVILLE
Mailing Address - State:RI
Mailing Address - Zip Code:02828-1730
Mailing Address - Country:US
Mailing Address - Phone:401-339-1816
Mailing Address - Fax:401-830-5729
Practice Address - Street 1:31 SMITH AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:GREENVILLE
Practice Address - State:RI
Practice Address - Zip Code:02828-1730
Practice Address - Country:US
Practice Address - Phone:401-339-1816
Practice Address - Fax:401-830-5729
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS00725103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI30156-5OtherBLUE CROSS
RI408421OtherBLUE CHIP