Provider Demographics
NPI:1356716740
Name:DEEDE, JENNIFER
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:DEEDE
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 1:2800 MARCUS AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1113
Mailing Address - Country:US
Mailing Address - Phone:516-622-6000
Mailing Address - Fax:516-622-6075
Practice Address - Street 1:2800 MARCUS AVE
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1113
Practice Address - Country:US
Practice Address - Phone:516-622-6000
Practice Address - Fax:516-622-6075
Is Sole Proprietor?:No
Enumeration Date:2015-12-10
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012063363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant