Provider Demographics
NPI:1730440645
Name:COLE, JENNIFER (MSED)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:COLE
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5748
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-0529
Mailing Address - Country:US
Mailing Address - Phone:631-683-7048
Mailing Address - Fax:
Practice Address - Street 1:90 HENRY ST
Practice Address - Street 2:
Practice Address - City:INWOOD
Practice Address - State:NY
Practice Address - Zip Code:11096-2335
Practice Address - Country:US
Practice Address - Phone:516-239-2182
Practice Address - Fax:718-327-3132
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-06
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY514225340174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist