Provider Demographics
NPI:1528840121
Name:MATHIS, JENNIFER (LAC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MATHIS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:147 MIDDLESEX RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14610-1150
Mailing Address - Country:US
Mailing Address - Phone:585-233-5289
Mailing Address - Fax:
Practice Address - Street 1:2139 N UNION ST STE 7A
Practice Address - Street 2:
Practice Address - City:SPENCERPORT
Practice Address - State:NY
Practice Address - Zip Code:14559-1261
Practice Address - Country:US
Practice Address - Phone:585-746-2187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-18
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007401171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist