Provider Demographics
NPI:1699253088
Name:BROSS, JENNIFER ERIN
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ERIN
Last Name:BROSS
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 1:102 BUCKNELL RD
Mailing Address - Street 2:
Mailing Address - City:WEST SAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11796-1005
Mailing Address - Country:US
Mailing Address - Phone:631-256-6079
Mailing Address - Fax:
Practice Address - Street 1:102 BUCKNELL RD
Practice Address - Street 2:
Practice Address - City:WEST SAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11796
Practice Address - Country:US
Practice Address - Phone:516-319-1781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-30
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty