Provider Demographics
NPI:1275244758
Name:FENTON, JONATHAN REVAI (CPSS)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:REVAI
Last Name:FENTON
Suffix:
Gender:M
Credentials:CPSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 ELIZABETH ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-2413
Mailing Address - Country:US
Mailing Address - Phone:315-939-3176
Mailing Address - Fax:
Practice Address - Street 1:624 ELIZABETH ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-2413
Practice Address - Country:US
Practice Address - Phone:315-939-3176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-06
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNYCPS-2152OtherNYS PEER SUPPORT SPECIALIST