Provider Demographics
NPI:1962672329
Name:RESNICK, JEN (MSTOM, LAC)
Entity Type:Individual
Prefix:
First Name:JEN
Middle Name:
Last Name:RESNICK
Suffix:
Gender:F
Credentials:MSTOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:367 CLINTON ST APT 3
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11231-3602
Mailing Address - Country:US
Mailing Address - Phone:510-205-6783
Mailing Address - Fax:
Practice Address - Street 1:36 RIVINGTON ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002
Practice Address - Country:US
Practice Address - Phone:212-945-7300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-01
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNYS-003223171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist