Provider Demographics
NPI:1760720163
Name:NICOTINA, JENNA M
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:M
Last Name:NICOTINA
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 1:145 CHESTER DR
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10710-1924
Mailing Address - Country:US
Mailing Address - Phone:914-433-9122
Mailing Address - Fax:
Practice Address - Street 1:145 CHESTER DR
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10710-1924
Practice Address - Country:US
Practice Address - Phone:914-433-9122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-21
Last Update Date:2013-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst