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General NPI Number Information
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NPI Number | 1336482223
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Entity Type | Organization
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Legal Business Name | JACK & JILL DEVELOPMENTAL SERVICES, SLP, OT & PSYCHOLOGY, PLLP
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Dates
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Enumeration Date | 03/29/2013
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Last Update Date | 03/29/2013
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Provider Practice Location Address
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Address Line | 17 N MAIN ST
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City | LIBERTY
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State | NY
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Zip | 12754-1807
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Country | US
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Telephone | 845-292-4134
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Fax | 845-292-4134
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Provider Business Mailing Address
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Address Line | 17 N MAIN ST
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City | LIBERTY
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State | NY
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Zip | 12754-1807
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Country | US
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Telephone | 845-292-4134
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Fax | 845-292-4134
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Authorized Official
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Title or Position | PARTNER
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Name | DR. JEFFREY PETER JENSEN
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Credential | PH.D.
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Telephone | 845-292-4134
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 252Y00000X
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Taxonomy Name | Early Intervention Provider Agency
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License Number | 008719
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License Number State | NY
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