Healthcare Provider Details

I. General information

NPI: 1194046292
Provider Name (Legal Business Name): JAMUNA THEVENTHIRAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2010
Last Update Date: 09/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 6TH ST
BROOKLYN NY
11215
US

IV. Provider business mailing address

28 BRIGHAM LN
PORTSMOUTH NH
03801-8431
US

V. Phone/Fax

Practice location:
  • Phone: 718-780-3000
  • Fax:
Mailing address:
  • Phone: 646-750-5407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number15972
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number265380
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: