Provider Demographics
NPI:1679734123
Name:LANDOLT, JENNIFER LOU (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:LOU
Last Name:LANDOLT
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:232 E 26TH
Mailing Address - Street 2:#3
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010
Mailing Address - Country:US
Mailing Address - Phone:646-284-7282
Mailing Address - Fax:
Practice Address - Street 1:55 HATCHETTS HILL RD
Practice Address - Street 2:
Practice Address - City:OLD LYME
Practice Address - State:CT
Practice Address - Zip Code:06371-1534
Practice Address - Country:US
Practice Address - Phone:800-370-3651
Practice Address - Fax:877-515-7147
Is Sole Proprietor?:No
Enumeration Date:2008-06-18
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY401083-1363LP0808X
CT7709363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health