Provider Demographics
NPI:1134481823
Name:WILL, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WILL
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 1:54 ALCOLADE DR E
Mailing Address - Street 2:
Mailing Address - City:SHIRLEY
Mailing Address - State:NY
Mailing Address - Zip Code:11967-3802
Mailing Address - Country:US
Mailing Address - Phone:631-395-2745
Mailing Address - Fax:
Practice Address - Street 1:54 ALCOLADE DR E
Practice Address - Street 2:
Practice Address - City:SHIRLEY
Practice Address - State:NY
Practice Address - Zip Code:11967-3802
Practice Address - Country:US
Practice Address - Phone:631-395-2745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-09
Last Update Date:2012-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY713940174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist