Provider Demographics
NPI:1447522073
Name:EGAN, JENNIFER ANN (MA)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ANN
Last Name:EGAN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 BALSAM LN
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-1627
Mailing Address - Country:US
Mailing Address - Phone:631-838-8053
Mailing Address - Fax:631-543-2633
Practice Address - Street 1:39 BALSAM LN
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-1627
Practice Address - Country:US
Practice Address - Phone:631-838-8053
Practice Address - Fax:631-543-2633
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-27
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY683924961174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist