Healthcare Provider Details

I. General information

NPI: 1700105277
Provider Name (Legal Business Name): JENNIFER LUE ZITKOV L.AC.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2010
Last Update Date: 05/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 W WATER ST
PAINTED POST NY
14870-1131
US

IV. Provider business mailing address

204 W WATER ST
PAINTED POST NY
14870-1131
US

V. Phone/Fax

Practice location:
  • Phone: 607-684-7068
  • Fax: 607-936-1559
Mailing address:
  • Phone: 607-684-7068
  • Fax: 607-936-1559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number004264
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: