Healthcare Provider Details

I. General information

NPI: 1265713119
Provider Name (Legal Business Name): JENNIFER DEROLLER M.S., ATR-BC, LCAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2011
Last Update Date: 09/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 HUMBOLDT ST
ROCHESTER NY
14610-1059
US

IV. Provider business mailing address

175 HUMBOLDT ST
ROCHESTER NY
14610-1059
US

V. Phone/Fax

Practice location:
  • Phone: 315-253-5383
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number001349
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: