=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255693032
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER L SWENNING MS, ED
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2012
-----------------------------------------------------
Last Update Date | 11/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3 WALNUT ST
-----------------------------------------------------
City | CENTEREACH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11720-1725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-639-9280
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4 BEECH ST S
-----------------------------------------------------
City | LAKE RONKONKOMA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11779-4413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 16877257
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 687269
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------