Provider Demographics
NPI:1154699940
Name:STREET, JENNIFER E
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:E
Last Name:STREET
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:E
Other - Last Name:AVERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9076 NORTH RD
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:13030-9662
Mailing Address - Country:US
Mailing Address - Phone:315-687-2280
Mailing Address - Fax:315-687-2281
Practice Address - Street 1:9076 NORTH RD
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:NY
Practice Address - Zip Code:13030-9662
Practice Address - Country:US
Practice Address - Phone:315-687-2280
Practice Address - Fax:315-687-2281
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-07
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010725-1251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)