Provider Demographics
NPI:1568104438
Name:RIVERA, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:RIVERA
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 1:13 GRANDVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-6316
Mailing Address - Country:US
Mailing Address - Phone:845-699-3742
Mailing Address - Fax:
Practice Address - Street 1:2 GLENMERE COVE RD
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:NY
Practice Address - Zip Code:10924-6059
Practice Address - Country:US
Practice Address - Phone:845-291-4740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-11
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013212-01225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant