Provider Demographics
NPI:1326635293
Name:MONTESDEOCA, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MONTESDEOCA
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 1:240 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11221-3444
Mailing Address - Country:US
Mailing Address - Phone:917-774-2460
Mailing Address - Fax:888-975-7704
Practice Address - Street 1:10818 QUEENS BLVD STE 4A5TH
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-4748
Practice Address - Country:US
Practice Address - Phone:917-774-2460
Practice Address - Fax:888-975-7704
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-28
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY256260OtherEARLY INTERVENTION PROGRAM