Healthcare Provider Details

I. General information

NPI: 1215049093
Provider Name (Legal Business Name): JENNIFER W GILLIN PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNIFER W KETNER PSYD

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99B MAIN ST
WESTHAMPTON BEACH NY
11978-2607
US

IV. Provider business mailing address

PO BOX 195
WESTHAMPTON NY
11977-0195
US

V. Phone/Fax

Practice location:
  • Phone: 631-288-3969
  • Fax:
Mailing address:
  • Phone: 631-682-0265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number015710
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: