Provider Demographics
NPI:1639311228
Name:BATES, JENNIFER LYNN
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNN
Last Name:BATES
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 1:1110 ROUTE 55
Mailing Address - Street 2:
Mailing Address - City:LAGRANGEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12540-5045
Mailing Address - Country:US
Mailing Address - Phone:845-473-8445
Mailing Address - Fax:
Practice Address - Street 1:452 CAMBY RD
Practice Address - Street 2:
Practice Address - City:VERBANK
Practice Address - State:NY
Practice Address - Zip Code:12585-5304
Practice Address - Country:US
Practice Address - Phone:845-677-0031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-30
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6929631744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management