Provider Demographics
NPI:1346322450
Name:PRENDERGAST, JANE M (NP)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:M
Last Name:PRENDERGAST
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
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Mailing Address - Street 1:338 FRENCHS BAY RD
Mailing Address - Street 2:
Mailing Address - City:TULLY
Mailing Address - State:NY
Mailing Address - Zip Code:13159-9440
Mailing Address - Country:US
Mailing Address - Phone:315-317-6940
Mailing Address - Fax:
Practice Address - Street 1:218 STONE ST FL 2
Practice Address - Street 2:COMMUNITY CLINIC OF JEFFERSON COUNTY
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-3211
Practice Address - Country:US
Practice Address - Phone:315-782-7445
Practice Address - Fax:315-779-1184
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2011-07-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY303635363LA2200X
NYF400868363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ41522Medicare UPIN