Provider Demographics
NPI:1306115704
Name:KING, JENNIFER RUTH
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RUTH
Last Name:KING
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 1:7 N ERIE ST
Mailing Address - Street 2:
Mailing Address - City:MAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14757-1095
Mailing Address - Country:US
Mailing Address - Phone:716-753-4104
Mailing Address - Fax:716-753-4230
Practice Address - Street 1:10825 BENNETT RD
Practice Address - Street 2:
Practice Address - City:DUNKIRK
Practice Address - State:NY
Practice Address - Zip Code:14048-3507
Practice Address - Country:US
Practice Address - Phone:716-363-3550
Practice Address - Fax:716-753-4230
Is Sole Proprietor?:No
Enumeration Date:2011-12-14
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY25209101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)