Healthcare Provider Details

I. General information

NPI: 1346322450
Provider Name (Legal Business Name): JANE M PRENDERGAST NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 07/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 STONE ST FL 2 COMMUNITY CLINIC OF JEFFERSON COUNTY
WATERTOWN NY
13601-3211
US

IV. Provider business mailing address

338 FRENCHS BAY RD
TULLY NY
13159-9440
US

V. Phone/Fax

Practice location:
  • Phone: 315-782-7445
  • Fax: 315-779-1184
Mailing address:
  • Phone: 315-317-6940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number303635
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF400868
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: