Provider Demographics
NPI:1366570780
Name:SUTHERLAND, JENNIFER (PSYD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:SUTHERLAND
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 AVENUE B
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-1403
Mailing Address - Country:US
Mailing Address - Phone:631-676-6767
Mailing Address - Fax:
Practice Address - Street 1:1563 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:NY
Practice Address - Zip Code:11769-1322
Practice Address - Country:US
Practice Address - Phone:631-563-3162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016954103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist