Provider Demographics
NPI:1124275631
Name:BAKER, JENNESE (PA)
Entity type:Individual
Prefix:
First Name:JENNESE
Middle Name:
Last Name:BAKER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21604 UNION TPKE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11364-3525
Mailing Address - Country:US
Mailing Address - Phone:718-465-3200
Mailing Address - Fax:718-465-9792
Practice Address - Street 1:21604 UNION TPKE
Practice Address - Street 2:
Practice Address - City:OAKLAND GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11364-3525
Practice Address - Country:US
Practice Address - Phone:718-465-3200
Practice Address - Fax:718-465-9792
Is Sole Proprietor?:No
Enumeration Date:2008-08-26
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008661363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical