Provider Demographics
NPI:1326517764
Name:TRAVIS, JENNIFER LYN
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYN
Last Name:TRAVIS
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 1:59 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:MAHOPAC
Mailing Address - State:NY
Mailing Address - Zip Code:10541-4640
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:59 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:MAHOPAC
Practice Address - State:NY
Practice Address - Zip Code:10541-4640
Practice Address - Country:US
Practice Address - Phone:845-416-2747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-14
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool