Provider Demographics
NPI:1639606981
Name:VILLA, JENNIFER SUZANNE (LAC)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:SUZANNE
Last Name:VILLA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:SUZANNE
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:1507 PROVIDENCE DR
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:NY
Mailing Address - Zip Code:14580-9492
Mailing Address - Country:US
Mailing Address - Phone:315-730-5175
Mailing Address - Fax:
Practice Address - Street 1:625 AYRAULT RD
Practice Address - Street 2:
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-3076
Practice Address - Country:US
Practice Address - Phone:585-465-1056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-17
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005978171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist