Provider Demographics
NPI:1699037960
Name:WEISBERG, JENNIFER (MSED)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
Last Name:WEISBERG
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:SCICCHITANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 SCOUTING BLVD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-2220
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 SCOUTING BLVD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-2220
Practice Address - Country:US
Practice Address - Phone:631-297-3201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-13
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY805676174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist