Provider Demographics
NPI:1851761654
Name:MCCAMMON, JENESIA
Entity Type:Individual
Prefix:
First Name:JENESIA
Middle Name:
Last Name:MCCAMMON
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 1:3321 AVENUE M
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210-5421
Mailing Address - Country:US
Mailing Address - Phone:718-531-1800
Mailing Address - Fax:
Practice Address - Street 1:3321 AVENUE M
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-5421
Practice Address - Country:US
Practice Address - Phone:718-531-1800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-06
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY982847151252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYKN70703NMedicaid