Provider Demographics
NPI:1912135682
Name:DYER, JENNIFER LYNNE (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNNE
Last Name:DYER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:484 HAWKINS AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-4248
Mailing Address - Country:US
Mailing Address - Phone:631-467-4221
Mailing Address - Fax:631-467-4233
Practice Address - Street 1:484 HAWKINS AVE
Practice Address - Street 2:
Practice Address - City:LAKE RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-4248
Practice Address - Country:US
Practice Address - Phone:631-467-4221
Practice Address - Fax:631-467-4233
Is Sole Proprietor?:No
Enumeration Date:2009-07-01
Last Update Date:2009-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024413-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist