Healthcare Provider Details

I. General information

NPI: 1710814199
Provider Name (Legal Business Name): JENNIFER DUTTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2026
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1235 MONTAUK HWY
MASTIC NY
11950-2917
US

IV. Provider business mailing address

298 MOUNT VERNON AVE
MEDFORD NY
11763-3113
US

V. Phone/Fax

Practice location:
  • Phone: 631-345-0083
  • Fax:
Mailing address:
  • Phone: 631-786-7610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberNYCPS-4300
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: