Provider Demographics
NPI:1891962395
Name:THERIOT, JENNIFER LEIGH (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEIGH
Last Name:THERIOT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 BROAD ST STE 1
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-4381
Mailing Address - Country:US
Mailing Address - Phone:518-798-9538
Mailing Address - Fax:518-798-9576
Practice Address - Street 1:84 BROAD ST STE 1
Practice Address - Street 2:
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-4381
Practice Address - Country:US
Practice Address - Phone:518-798-9538
Practice Address - Fax:518-798-9576
Is Sole Proprietor?:No
Enumeration Date:2008-05-14
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY243818208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics