Provider Demographics
NPI:1831323179
Name:HOLBROOK, JENNIFER LEE
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LEE
Last Name:HOLBROOK
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 1:1038 OLD STATE ROUTE 31
Mailing Address - Street 2:
Mailing Address - City:JORDAN
Mailing Address - State:NY
Mailing Address - Zip Code:13080-9718
Mailing Address - Country:US
Mailing Address - Phone:315-277-5244
Mailing Address - Fax:
Practice Address - Street 1:1038 OLD STATE ROUTE 31
Practice Address - Street 2:
Practice Address - City:JORDAN
Practice Address - State:NY
Practice Address - Zip Code:13080-9718
Practice Address - Country:US
Practice Address - Phone:315-277-5244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-13
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY294660-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse