Provider Demographics
NPI:1770840597
Name:HOOSE, JENNIFER LISA (RN)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LISA
Last Name:HOOSE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:262 CANAL ST
Mailing Address - Street 2:
Mailing Address - City:MONTOUR FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:14865-9600
Mailing Address - Country:US
Mailing Address - Phone:607-535-7517
Mailing Address - Fax:607-535-7802
Practice Address - Street 1:262 CANAL ST
Practice Address - Street 2:
Practice Address - City:MONTOUR FALLS
Practice Address - State:NY
Practice Address - Zip Code:14865-9600
Practice Address - Country:US
Practice Address - Phone:607-535-7517
Practice Address - Fax:607-535-7802
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-18
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY480379-1251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY15-6002322Medicaid