Provider Demographics
NPI:1649932393
Name:MCCLINTON, JENNIFER DAWN (LMT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DAWN
Last Name:MCCLINTON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 DEKALB AVE APT 202
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10605-6449
Mailing Address - Country:US
Mailing Address - Phone:347-886-3141
Mailing Address - Fax:
Practice Address - Street 1:95 CHURCH ST STE 210
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10601-1515
Practice Address - Country:US
Practice Address - Phone:845-513-6805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-11
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028479225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY028479OtherLICENCE NUMBER
NY028479OtherLICENSE NUMBER