Healthcare Provider Details

I. General information

NPI: 1386941193
Provider Name (Legal Business Name): JENNIFER DAVIS MACBLANE C.N.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2011
Last Update Date: 08/03/2022
Certification Date: 08/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 PROSPECT AVE
SYRACUSE NY
13203-1807
US

IV. Provider business mailing address

4853 THORNWOOD DR
LIVERPOOL NY
13088-5811
US

V. Phone/Fax

Practice location:
  • Phone: 315-448-5840
  • Fax:
Mailing address:
  • Phone: 315-569-1050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number28001429
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: