Healthcare Provider Details

I. General information

NPI: 1114964350
Provider Name (Legal Business Name): JENNIFER L DYL PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 06/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 SMITH AVE SUITE 2
GREENVILLE RI
02828-1730
US

IV. Provider business mailing address

31 SMITH AVE SUITE 2
GREENVILLE RI
02828-1730
US

V. Phone/Fax

Practice location:
  • Phone: 401-339-1816
  • Fax: 401-830-5729
Mailing address:
  • Phone: 401-339-1816
  • Fax: 401-830-5729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS00725
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: