Provider Demographics
NPI:1790148237
Name:HERNANDEZ, JENNIFER GUADALUPE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:GUADALUPE
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:PO BOX 385
Mailing Address - Street 2:
Mailing Address - City:BOHEMIA
Mailing Address - State:NY
Mailing Address - Zip Code:11716-0385
Mailing Address - Country:US
Mailing Address - Phone:631-880-1125
Mailing Address - Fax:
Practice Address - Street 1:185 OVAL DR
Practice Address - Street 2:
Practice Address - City:ISLANDIA
Practice Address - State:NY
Practice Address - Zip Code:11749-1402
Practice Address - Country:US
Practice Address - Phone:631-880-1125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-01
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator