Healthcare Provider Details

I. General information

NPI: 1689566390
Provider Name (Legal Business Name): JENNA MARIE VANWEELDEN LCAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JUNO VANWEELDEN LCAT

II. Dates (important events)

Enumeration Date: 07/17/2025
Last Update Date: 07/17/2025
Certification Date: 07/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 OLD MAIN ST STE 207
FISHKILL NY
12524-1883
US

IV. Provider business mailing address

66 ROUNDTREE CT
BEACON NY
12508-2128
US

V. Phone/Fax

Practice location:
  • Phone: 917-300-1332
  • Fax:
Mailing address:
  • Phone: 513-262-0808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101200000X
TaxonomyDrama Therapist
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: