MEDICARE: DR. JENNIFER LORI NADDELL PH.D.

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	103TC0700X	Clinical Psychologist	015411-1	NY
2	103TC0700X	Clinical Psychologist	015411	NY
3	103T00000X	Psychologist	015411-1	NY

General Provider Information

NPI Number	:	1942331533
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JENNIFER LORI NADDELL PH.D.

Provider Business Mailing Address
First Line	:	119 W 57TH ST STE 1212
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10019-2401
Country	:	US
Telephone Number	:	917-270-9242
Fax Number	:

Provider Business Practice Location Address
First Line	:	119 W 57TH ST STE 1212
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10019-2401
Country	:	US
Telephone Number	:	917-270-9242
Fax Number	:

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

Provider Enumeration Date	:	03/08/2007
Last Update Date	:	08/07/2019

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