Provider Demographics
NPI:1902005259
Name:DENNIS, JEAN M
Entity Type:Individual
Prefix:MS
First Name:JEAN
Middle Name:M
Last Name:DENNIS
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 1:155 DRYDEN HARFORD RD
Mailing Address - Street 2:
Mailing Address - City:DRYDEN
Mailing Address - State:NY
Mailing Address - Zip Code:13053-9773
Mailing Address - Country:US
Mailing Address - Phone:607-844-4861
Mailing Address - Fax:
Practice Address - Street 1:155 DRYDEN HARFORD RD
Practice Address - Street 2:
Practice Address - City:DRYDEN
Practice Address - State:NY
Practice Address - Zip Code:13053-9773
Practice Address - Country:US
Practice Address - Phone:607-844-4861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-17
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY246496-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02641312Medicaid