Provider Demographics
NPI:1871978767
Name:RUDIN, JENNIFER PHYLLIS
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:PHYLLIS
Last Name:RUDIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 JAY ST
Mailing Address - Street 2:
Mailing Address - City:BARDONIA
Mailing Address - State:NY
Mailing Address - Zip Code:10954-2136
Mailing Address - Country:US
Mailing Address - Phone:845-826-0293
Mailing Address - Fax:
Practice Address - Street 1:41 JAY ST
Practice Address - Street 2:
Practice Address - City:BARDONIA
Practice Address - State:NY
Practice Address - Zip Code:10954-2136
Practice Address - Country:US
Practice Address - Phone:845-826-0293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-21
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst