=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922579432
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER JEAN DAVIS LCAT, ATR-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2018
-----------------------------------------------------
Last Update Date | 12/09/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 165 BEACH 116TH ST
-----------------------------------------------------
City | ROCKAWAY PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11694-2411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-415-3878
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 195 BEACH 100TH ST
-----------------------------------------------------
City | ROCKAWAY PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11694-2822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-415-3878
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 221700000X
-----------------------------------------------------
Taxonomy Name | Art Therapist
-----------------------------------------------------
License Number | 001908
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------