Provider Demographics
NPI:1013186162
Name:JENNAS LEUNG, OLIVE NERISSA (LPN)
Entity Type:Individual
Prefix:MRS
First Name:OLIVE
Middle Name:NERISSA
Last Name:JENNAS LEUNG
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 130269
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11213
Mailing Address - Country:US
Mailing Address - Phone:917-846-3985
Mailing Address - Fax:
Practice Address - Street 1:3140 77TH ST
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11370
Practice Address - Country:US
Practice Address - Phone:718-672-4898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-22
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2022901164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01197800Medicaid