Provider Demographics
NPI:1710524582
Name:POLAN, JENNA
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:POLAN
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 1:79 SOMERSET DR
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-2873
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1737 VETERANS MEMORIAL HWY STE 1
Practice Address - Street 2:
Practice Address - City:ISLANDIA
Practice Address - State:NY
Practice Address - Zip Code:11749-1529
Practice Address - Country:US
Practice Address - Phone:631-479-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-29
Last Update Date:2019-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician