Provider Demographics
NPI:1992085153
Name:REGAN, JENNIFER MARIE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:REGAN
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 1:4536 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226
Mailing Address - Country:US
Mailing Address - Phone:716-560-6362
Mailing Address - Fax:
Practice Address - Street 1:4536 MAIN ST
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-3828
Practice Address - Country:US
Practice Address - Phone:716-560-6362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-19
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY27 023297225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist