Provider Demographics
NPI:1679671424
Name:MADDISON, JENNIFER (NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MADDISON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 ELMWOOD AVE
Mailing Address - Street 2:BOX SURG
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-8410
Mailing Address - Country:US
Mailing Address - Phone:585-275-4435
Mailing Address - Fax:585-276-2370
Practice Address - Street 1:601 ELMWOOD AVE
Practice Address - Street 2:BOX SURG
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642-8410
Practice Address - Country:US
Practice Address - Phone:585-275-4435
Practice Address - Fax:585-276-2370
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF381250363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03274095Medicaid
NYJ4000345577Medicare PIN