Provider Demographics
NPI:1912221037
Name:DOHERTY, JENNIFER M
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:DOHERTY
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 1:2 KELLY CT
Mailing Address - Street 2:
Mailing Address - City:STORMVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12582-5609
Mailing Address - Country:US
Mailing Address - Phone:570-295-0901
Mailing Address - Fax:
Practice Address - Street 1:2 KELLY COURT
Practice Address - Street 2:
Practice Address - City:STORMVILLE
Practice Address - State:NY
Practice Address - Zip Code:12582
Practice Address - Country:US
Practice Address - Phone:570-295-0901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-18
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor