Provider Demographics
NPI:1851012280
Name:HALL, JENNIFER ROSE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ROSE
Last Name:HALL
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 1:49 REEVES AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-1627
Mailing Address - Country:US
Mailing Address - Phone:631-561-5125
Mailing Address - Fax:
Practice Address - Street 1:197 HALF HOLLOW RD
Practice Address - Street 2:
Practice Address - City:DIX HILLS
Practice Address - State:NY
Practice Address - Zip Code:11746-5861
Practice Address - Country:US
Practice Address - Phone:631-370-1694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-05
Last Update Date:2022-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY795795163WP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent