Healthcare Provider Details

I. General information

NPI: 1114385887
Provider Name (Legal Business Name): JENNIFER MANDER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2016
Last Update Date: 02/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WASHINGTON ST ELMIRA PSYCHIATRIC CENTER
ELMIRA NY
14901-2898
US

IV. Provider business mailing address

12 N PARK ST
SENECA FALLS NY
13148-1437
US

V. Phone/Fax

Practice location:
  • Phone: 607-737-4711
  • Fax:
Mailing address:
  • Phone: 315-568-9412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberNYCPS-P-413
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: