Provider Demographics
NPI:1699037630
Name:BERMAN, JENNA
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:BERMAN
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 1:66 CRESCENT DR
Mailing Address - Street 2:
Mailing Address - City:OLD BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11804-1528
Mailing Address - Country:US
Mailing Address - Phone:631-664-1531
Mailing Address - Fax:
Practice Address - Street 1:66 CRESCENT DR
Practice Address - Street 2:APT 8O
Practice Address - City:OLD BETHPAGE
Practice Address - State:NY
Practice Address - Zip Code:11804-1528
Practice Address - Country:US
Practice Address - Phone:631-664-1531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-14
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY321488939174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist