MEDICARE: JANE M PRENDERGAST NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	303635	NY
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	F400868	NY

General Provider Information

NPI Number	:	1346322450
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JANE M PRENDERGAST NP

Provider Business Mailing Address
First Line	:	338 FRENCHS BAY RD
Second Line	:
City	:	TULLY
State	:	NY
Zip	:	13159-9440
Country	:	US
Telephone Number	:	315-317-6940
Fax Number	:

Provider Business Practice Location Address
First Line	:	218 STONE ST FL 2
Second Line	:	COMMUNITY CLINIC OF JEFFERSON COUNTY
City	:	WATERTOWN
State	:	NY
Zip	:	13601-3211
Country	:	US
Telephone Number	:	315-782-7445
Fax Number	:	315-779-1184

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/19/2006
Last Update Date	:	07/29/2011

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