Provider Demographics
NPI:1700105277
Name:ZITKOV, JENNIFER LUE (LAC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LUE
Last Name:ZITKOV
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 W WATER ST
Mailing Address - Street 2:
Mailing Address - City:PAINTED POST
Mailing Address - State:NY
Mailing Address - Zip Code:14870-1131
Mailing Address - Country:US
Mailing Address - Phone:607-684-7068
Mailing Address - Fax:607-936-1559
Practice Address - Street 1:204 W WATER ST
Practice Address - Street 2:
Practice Address - City:PAINTED POST
Practice Address - State:NY
Practice Address - Zip Code:14870-1131
Practice Address - Country:US
Practice Address - Phone:607-684-7068
Practice Address - Fax:607-936-1559
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-24
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004264171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist