Provider Demographics
NPI:1407194467
Name:DRAKE, JENNIFER M
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:DRAKE
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 1:1608 AVALON PINES DR
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-5141
Mailing Address - Country:US
Mailing Address - Phone:631-807-8287
Mailing Address - Fax:
Practice Address - Street 1:1608 AVALON PINES DR
Practice Address - Street 2:
Practice Address - City:CORAM
Practice Address - State:NY
Practice Address - Zip Code:11727-5141
Practice Address - Country:US
Practice Address - Phone:631-807-8287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-27
Last Update Date:2013-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY814364174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist