Provider Demographics
NPI:1376364877
Name:VIVIANO, JENNIFER LAUREN
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LAUREN
Last Name:VIVIANO
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 1:322 OAKDALE RD
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-1140
Mailing Address - Country:US
Mailing Address - Phone:607-348-5483
Mailing Address - Fax:
Practice Address - Street 1:322 OAKDALE RD
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-1140
Practice Address - Country:US
Practice Address - Phone:607-348-5483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-18
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY112548104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker