Provider Demographics
NPI:1366048357
Name:DAVIS, JENNIFER LYNN (NP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 CORPORATE WAY STE 2M
Mailing Address - Street 2:
Mailing Address - City:VALLEY COTTAGE
Mailing Address - State:NY
Mailing Address - Zip Code:10989-2027
Mailing Address - Country:US
Mailing Address - Phone:845-996-8176
Mailing Address - Fax:718-362-8185
Practice Address - Street 1:13611 SCHANG RD
Practice Address - Street 2:
Practice Address - City:EAST AURORA
Practice Address - State:NY
Practice Address - Zip Code:14052-9595
Practice Address - Country:US
Practice Address - Phone:845-996-8176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-07
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF310104-01363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF310104-01OtherLICENSE NUMBER OFFICE OF PROFESSIONALS