Provider Demographics
NPI:1124379805
Name:WHITE, JINELL
Entity Type:Individual
Prefix:
First Name:JINELL
Middle Name:
Last Name:WHITE
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 1:214 GREENE AVE
Mailing Address - Street 2:
Mailing Address - City:SAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11782-3056
Mailing Address - Country:US
Mailing Address - Phone:631-553-2281
Mailing Address - Fax:631-244-7917
Practice Address - Street 1:214 GREENE AVE
Practice Address - Street 2:
Practice Address - City:SAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11782-3056
Practice Address - Country:US
Practice Address - Phone:631-553-2281
Practice Address - Fax:631-244-7917
Is Sole Proprietor?:No
Enumeration Date:2012-09-21
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1074149174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist