Provider Demographics
NPI:1205405743
Name:WHITMORE, JENNIFER LAUREN
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LAUREN
Last Name:WHITMORE
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 1:4214 TEALL BCH
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:NY
Mailing Address - Zip Code:14456-9278
Mailing Address - Country:US
Mailing Address - Phone:315-719-1945
Mailing Address - Fax:
Practice Address - Street 1:367 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:NY
Practice Address - Zip Code:13165-1662
Practice Address - Country:US
Practice Address - Phone:315-787-4977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-19
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY310265363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner