Provider Demographics
NPI:1710486253
Name:PENN, JALEESA (MS)
Entity Type:Individual
Prefix:
First Name:JALEESA
Middle Name:
Last Name:PENN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1299 WORLD AVE
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-2643
Mailing Address - Country:US
Mailing Address - Phone:516-260-3547
Mailing Address - Fax:
Practice Address - Street 1:300 GARDEN CITY PLZ
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-3302
Practice Address - Country:US
Practice Address - Phone:516-747-9030
Practice Address - Fax:516-877-0998
Is Sole Proprietor?:No
Enumeration Date:2018-02-11
Last Update Date:2018-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1062161161174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist