Healthcare Provider Details

I. General information

NPI: 1871607184
Provider Name (Legal Business Name): BETH ANN JAYNE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 02/23/2021
Certification Date: 02/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

238 ARSENAL ST
WATERTOWN NY
13601-2504
US

IV. Provider business mailing address

238 ARSENAL ST
WATERTOWN NY
13601-2504
US

V. Phone/Fax

Practice location:
  • Phone: 315-782-9450
  • Fax: 315-782-2643
Mailing address:
  • Phone: 315-782-9450
  • Fax: 315-782-2643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number307832
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number307832
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: