Healthcare Provider Details

I. General information

NPI: 1366153728
Provider Name (Legal Business Name): JENNIFER ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2022
Last Update Date: 12/07/2022
Certification Date: 12/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 ACADEMY RD
ALBANY NY
12208-3103
US

IV. Provider business mailing address

36 BALLINA ST
TROY NY
12180-6153
US

V. Phone/Fax

Practice location:
  • Phone: 518-426-2600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number757678
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: