Provider Demographics
NPI:1215049093
Name:GILLIN, JENNIFER W (PSYD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:W
Last Name:GILLIN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:W
Other - Last Name:KETNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:PO BOX 195
Mailing Address - Street 2:
Mailing Address - City:WESTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11977-0195
Mailing Address - Country:US
Mailing Address - Phone:631-682-0265
Mailing Address - Fax:
Practice Address - Street 1:99B MAIN ST
Practice Address - Street 2:
Practice Address - City:WESTHAMPTON BEACH
Practice Address - State:NY
Practice Address - Zip Code:11978-2607
Practice Address - Country:US
Practice Address - Phone:631-288-3969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015710103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY497164OtherVALUE OPTIONS
NY73361570OtherGHI/EMPIRE
NY497164OtherVALUE OPTIONS