Provider Demographics
NPI:1922579432
Name:DAVIS, JENNIFER JEAN (LCAT, ATR-BC)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:JEAN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LCAT, ATR-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 BEACH 100TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11694-2822
Mailing Address - Country:US
Mailing Address - Phone:718-415-3878
Mailing Address - Fax:
Practice Address - Street 1:165 BEACH 116TH ST
Practice Address - Street 2:
Practice Address - City:ROCKAWAY PARK
Practice Address - State:NY
Practice Address - Zip Code:11694-2411
Practice Address - Country:US
Practice Address - Phone:718-415-3878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-09
Last Update Date:2018-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001908221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt TherapistGroup - Single Specialty