Provider Demographics
NPI:1952962185
Name:RIVENBURGH, JENNIFER LYNN (NP-P)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNN
Last Name:RIVENBURGH
Suffix:
Gender:F
Credentials:NP-P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11-21 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:GLOVERSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12078-3964
Mailing Address - Country:US
Mailing Address - Phone:518-725-4310
Mailing Address - Fax:518-725-2988
Practice Address - Street 1:11-21 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:GLOVERSVILLE
Practice Address - State:NY
Practice Address - Zip Code:12078-3964
Practice Address - Country:US
Practice Address - Phone:518-725-4310
Practice Address - Fax:518-725-2988
Is Sole Proprietor?:No
Enumeration Date:2019-06-27
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY720511163W00000X
NYF402794363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse