Provider Demographics
NPI:1134439607
Name:O'DONNELL, JANE DOHERTY (CERTIFICATION)
Entity type:Individual
Prefix:MRS
First Name:JANE
Middle Name:DOHERTY
Last Name:O'DONNELL
Suffix:
Gender:F
Credentials:CERTIFICATION
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 LESTER DR
Mailing Address - Street 2:
Mailing Address - City:TAPPAN
Mailing Address - State:NY
Mailing Address - Zip Code:10983-1217
Mailing Address - Country:US
Mailing Address - Phone:845-680-1432
Mailing Address - Fax:
Practice Address - Street 1:140 LESTER DR
Practice Address - Street 2:
Practice Address - City:TAPPAN
Practice Address - State:NY
Practice Address - Zip Code:10983-1217
Practice Address - Country:US
Practice Address - Phone:845-680-1432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-18
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103TS0200X
103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool