Healthcare Provider Details

I. General information

NPI: 1699080655
Provider Name (Legal Business Name): JENCY THOMAS SAMUEL NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENCY JOHN THOMAS NP

II. Dates (important events)

Enumeration Date: 08/16/2010
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2125 RIVER RD STE 103
SCHENECTADY NY
12309-1108
US

IV. Provider business mailing address

6 WELLNESS WAY STE 201
LATHAM NY
12110-2156
US

V. Phone/Fax

Practice location:
  • Phone: 518-382-7500
  • Fax: 518-382-7572
Mailing address:
  • Phone: 518-782-3700
  • Fax: 518-782-3799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number337923
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier03600319
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: