Provider Demographics
NPI:1811672595
Name:RIVERA, JENNELLE
Entity type:Individual
Prefix:
First Name:JENNELLE
Middle Name:
Last Name:RIVERA
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 1:414 LELAND AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10473-3016
Mailing Address - Country:US
Mailing Address - Phone:646-334-6411
Mailing Address - Fax:
Practice Address - Street 1:349 E 149TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-5603
Practice Address - Country:US
Practice Address - Phone:718-993-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-20
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker