Provider Demographics
NPI:1265713119
Name:DEROLLER, JENNIFER (MS, ATR-BC, LCAT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DEROLLER
Suffix:
Gender:F
Credentials:MS, ATR-BC, LCAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 HUMBOLDT ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14610-1059
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:175 HUMBOLDT ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14610-1059
Practice Address - Country:US
Practice Address - Phone:315-253-5383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-06
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001349221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist