Provider Demographics
NPI:1760192934
Name:HERNANDEZ, JENNIFER CAITLIN
Entity Type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:CAITLIN
Last Name:HERNANDEZ
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 1:163 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-2610
Mailing Address - Country:US
Mailing Address - Phone:631-418-6531
Mailing Address - Fax:
Practice Address - Street 1:90 ADAMS AVE
Practice Address - Street 2:
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788-3631
Practice Address - Country:US
Practice Address - Phone:631-952-3333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-29
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator