Provider Demographics
NPI:1982026209
Name:MOLINO, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MOLINO
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 1:45 WHITEHEAD ST
Mailing Address - Street 2:
Mailing Address - City:SELKIRK
Mailing Address - State:NY
Mailing Address - Zip Code:12158-1771
Mailing Address - Country:US
Mailing Address - Phone:518-859-1742
Mailing Address - Fax:
Practice Address - Street 1:45 WHITEHEAD ST
Practice Address - Street 2:
Practice Address - City:SELKIRK
Practice Address - State:NY
Practice Address - Zip Code:12158-1771
Practice Address - Country:US
Practice Address - Phone:518-859-1742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-07
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY649614174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist