Provider Demographics
NPI:1558099051
Name:SWANSON, JENNIFER ELIZABETH LOLA
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ELIZABETH LOLA
Last Name:SWANSON
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 1:157 E 1ST ST STE 7
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-2656
Mailing Address - Country:US
Mailing Address - Phone:315-529-5607
Mailing Address - Fax:
Practice Address - Street 1:157 E 1ST ST STE 7
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-2656
Practice Address - Country:US
Practice Address - Phone:315-529-5607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-11
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health