Provider Demographics
NPI:1104253335
Name:SCANLON, JENNIFER MARIE
Entity type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:MARIE
Last Name:SCANLON
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 1:23 WOODS LN
Mailing Address - Street 2:
Mailing Address - City:CENTEREACH
Mailing Address - State:NY
Mailing Address - Zip Code:11720-2517
Mailing Address - Country:US
Mailing Address - Phone:631-335-4213
Mailing Address - Fax:
Practice Address - Street 1:239 KERRY ST
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-3817
Practice Address - Country:US
Practice Address - Phone:631-335-4213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY315519-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse