Provider Demographics
NPI:1770962151
Name:COSENZA, JEAN COLLEEN
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:COLLEEN
Last Name:COSENZA
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 1:1115 WISCONSIN RD
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:NY
Mailing Address - Zip Code:14047-9577
Mailing Address - Country:US
Mailing Address - Phone:716-570-8219
Mailing Address - Fax:
Practice Address - Street 1:1115 WISCONSIN RD
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:NY
Practice Address - Zip Code:14047-9577
Practice Address - Country:US
Practice Address - Phone:716-570-8219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-19
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor