Provider Demographics
NPI:1821248949
Name:THAKUR, JENNIFER (NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:THAKUR
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:AYOTTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:4870 BROAD RD
Mailing Address - Street 2:POB NORTH SUITE 3Q
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13215-2206
Mailing Address - Country:US
Mailing Address - Phone:315-492-5292
Mailing Address - Fax:315-701-0544
Practice Address - Street 1:4870 BROAD RD
Practice Address - Street 2:POB NORTH SUITE 3Q
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13215-2206
Practice Address - Country:US
Practice Address - Phone:315-492-5292
Practice Address - Fax:315-701-0544
Is Sole Proprietor?:No
Enumeration Date:2008-09-25
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY306245363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPENDINGOtherNYS LICENSE
NYPENDINGOtherNYS LICENSE