Healthcare Provider Details

I. General information

NPI: 1982980462
Provider Name (Legal Business Name): JENNIFER WIENER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2011
Last Update Date: 10/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

997 STAFFORD AVE
STATEN ISLAND NY
10309-2109
US

IV. Provider business mailing address

68 LESTER AVE
FREEPORT NY
11520-5913
US

V. Phone/Fax

Practice location:
  • Phone: 917-744-3976
  • Fax:
Mailing address:
  • Phone: 516-510-5439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number1108805
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: