Healthcare Provider Details

I. General information

NPI: 1043780364
Provider Name (Legal Business Name): JENNIFER P SULLIVAN CBS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2018
Last Update Date: 11/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 ARLINGTON AVE STE 4
POUGHKEEPSIE NY
12603-1603
US

IV. Provider business mailing address

33 ARLINGTON AVE STE 4
POUGHKEEPSIE NY
12603-1603
US

V. Phone/Fax

Practice location:
  • Phone: 845-473-5952
  • Fax:
Mailing address:
  • Phone: 845-473-5952
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: