Provider Demographics
NPI:1740585462
Name:JUDGE, JENNIFER E (PSYD,)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:E
Last Name:JUDGE
Suffix:
Gender:F
Credentials:PSYD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 FIELDSTONE DR
Mailing Address - Street 2:
Mailing Address - City:DELMAR
Mailing Address - State:NY
Mailing Address - Zip Code:12054-6703
Mailing Address - Country:US
Mailing Address - Phone:518-229-5459
Mailing Address - Fax:
Practice Address - Street 1:12 CENTURY HILL DR STE 105
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-2123
Practice Address - Country:US
Practice Address - Phone:518-351-7883
Practice Address - Fax:518-708-8055
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-12
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015497-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist