Provider Demographics
NPI:1346358983
Name:AXTELL, JENNIFER JOY (NP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:JOY
Last Name:AXTELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:JOY
Other - Last Name:BURNS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 488
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14240-0488
Mailing Address - Country:US
Mailing Address - Phone:716-433-1941
Mailing Address - Fax:716-439-1233
Practice Address - Street 1:175 WALNUT ST STE 7
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094-3775
Practice Address - Country:US
Practice Address - Phone:716-433-1941
Practice Address - Fax:716-439-1233
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY420806363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02810786Medicaid
NY02810786Medicaid