Provider Demographics
NPI:1790048122
Name:KIES, JENNIFER (MSED)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
Last Name:KIES
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 PEARTREE LN
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-4016
Mailing Address - Country:US
Mailing Address - Phone:631-382-7311
Mailing Address - Fax:631-382-7933
Practice Address - Street 1:49 WIRELESS BLVD
Practice Address - Street 2:SUITE 170
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788-3965
Practice Address - Country:US
Practice Address - Phone:631-382-7311
Practice Address - Fax:631-382-7311
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-20
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY8464171M00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator