Provider Demographics
NPI:1780045724
Name:KANALY, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:KANALY
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 1:75 BEEKMAN ST
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-1438
Mailing Address - Country:US
Mailing Address - Phone:518-562-7790
Mailing Address - Fax:
Practice Address - Street 1:287 JOHN BOSWELL RD
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:NY
Practice Address - Zip Code:12972
Practice Address - Country:US
Practice Address - Phone:518-420-2073
Practice Address - Fax:518-763-0895
Is Sole Proprietor?:No
Enumeration Date:2016-03-18
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY401976363LP0808X
NY40 401976363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health