Provider Demographics
NPI:1346339744
Name:DOOLAN, JENNIFER (NP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:DOOLAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 BELLE TERRE RD
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-1928
Mailing Address - Country:US
Mailing Address - Phone:631-474-6351
Mailing Address - Fax:
Practice Address - Street 1:12 BREWSTER LN
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-2922
Practice Address - Country:US
Practice Address - Phone:631-941-4480
Practice Address - Fax:631-941-4054
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF3040001363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF3040001OtherLICENSE
NYF3040001OtherLICENSE
NYF3040001OtherLICENSE
NYMD1232153OtherDEA