Provider Demographics
NPI:1558624833
Name:MCENTYRE, JEAN (TVI, O&M, SP ED)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:MCENTYRE
Suffix:
Gender:F
Credentials:TVI, O&M, SP ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6281 ROUTE 82
Mailing Address - Street 2:
Mailing Address - City:STANFORDVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12581-5867
Mailing Address - Country:US
Mailing Address - Phone:845-868-1211
Mailing Address - Fax:
Practice Address - Street 1:6281 ROUTE 82
Practice Address - Street 2:
Practice Address - City:STANFORDVILLE
Practice Address - State:NY
Practice Address - Zip Code:12581-5867
Practice Address - Country:US
Practice Address - Phone:845-868-1211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-21
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2232174400000X, 174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2232Medicaid