Healthcare Provider Details

I. General information

NPI: 1699064683
Provider Name (Legal Business Name): DR. JESSICA L HENNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2011
Last Update Date: 10/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 E MAIN ST
EAST ISLIP NY
11730-2711
US

IV. Provider business mailing address

4 GAINSVILLE DR
PLAINVIEW NY
11803-1210
US

V. Phone/Fax

Practice location:
  • Phone: 631-581-8600
  • Fax:
Mailing address:
  • Phone: 516-364-2050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number056072
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: