Provider Demographics
NPI:1447743406
Name:DUPPERT, JENNIFER L (PMHNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:DUPPERT
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 PALMER DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-1244
Mailing Address - Country:US
Mailing Address - Phone:315-450-1362
Mailing Address - Fax:
Practice Address - Street 1:30 WARREN ST
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-3602
Practice Address - Country:US
Practice Address - Phone:315-450-1362
Practice Address - Fax:617-779-1482
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-13
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY402392363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty