Healthcare Provider Details

I. General information

NPI: 1750168936
Provider Name (Legal Business Name): JNK NP IN PSYCHIATRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2023
Last Update Date: 09/12/2023
Certification Date: 09/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

470 ROUTE 211 E STE 24
MIDDLETOWN NY
10940-2252
US

IV. Provider business mailing address

PO BOX 1155
MONROE NY
10949-8155
US

V. Phone/Fax

Practice location:
  • Phone: 347-336-0582
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: KASAMBA JOSEPH
Title or Position: PMHNP-BC
Credential:
Phone: 347-336-0582