Provider Demographics
NPI:1528301587
Name:MEYER, JENNY ADELE (MD)
Entity type:Individual
Prefix:DR
First Name:JENNY
Middle Name:ADELE
Last Name:MEYER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JENNY
Other - Middle Name:ADELE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:111 E 210TH ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-2401
Mailing Address - Country:US
Mailing Address - Phone:718-920-4321
Mailing Address - Fax:
Practice Address - Street 1:90 PRESIDENTIAL PLZ FL 4
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-2240
Practice Address - Country:US
Practice Address - Phone:315-464-4243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-28
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2879952084N0400X
NY287995-12084N0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0008XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeuromuscular Medicine
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1528301587Medicaid