Provider Demographics
NPI:1245593417
Name:MADISON, JENNETTE J
Entity Type:Individual
Prefix:MRS
First Name:JENNETTE
Middle Name:J
Last Name:MADISON
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 1:31 SPACKENKILL RD
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12603-5317
Mailing Address - Country:US
Mailing Address - Phone:845-462-0079
Mailing Address - Fax:
Practice Address - Street 1:31 SPACKENKILL RD
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12603-5317
Practice Address - Country:US
Practice Address - Phone:845-462-0079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-21
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYCERTIFICATE 721036174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist