Provider Demographics
NPI:1619427960
Name:SOOD, JENNA (CNM)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:SOOD
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8900 VAN WYCK EXPY
Mailing Address - Street 2:RICHMOND HILL
Mailing Address - City:RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11418-2832
Mailing Address - Country:US
Mailing Address - Phone:203-570-4239
Mailing Address - Fax:
Practice Address - Street 1:3671 BROADWAY
Practice Address - Street 2:APT 28
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10031-1503
Practice Address - Country:US
Practice Address - Phone:203-570-4239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY702941163W00000X
NY001771367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00695941Medicaid