Provider Demographics
NPI:1942599154
Name:BAIN, JENNIFER M (MD, PHD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:BAIN
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 W 168TH ST
Mailing Address - Street 2:NEW, NY 10032
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3726
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:180 FORT WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3722
Practice Address - Country:US
Practice Address - Phone:646-426-3876
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-29
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2794182084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology