Provider Demographics
NPI:1316380579
Name:JURGENSEN, CECILE (EDS)
Entity Type:Individual
Prefix:
First Name:CECILE
Middle Name:
Last Name:JURGENSEN
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 PARK LN
Mailing Address - Street 2:EARLY EDUCATION CENTER
Mailing Address - City:HIGHLAND
Mailing Address - State:NY
Mailing Address - Zip Code:12528-2824
Mailing Address - Country:US
Mailing Address - Phone:845-883-5151
Mailing Address - Fax:845-883-6452
Practice Address - Street 1:40 PARK LN
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:NY
Practice Address - Zip Code:12528-2824
Practice Address - Country:US
Practice Address - Phone:845-883-5151
Practice Address - Fax:845-883-6452
Is Sole Proprietor?:No
Enumeration Date:2013-04-08
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1033422670Medicaid