Provider Demographics
NPI:1689224578
Name:SAMUEL, JENNIFER (PMHNP-BC)
Entity type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:SHAFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PMHNP
Mailing Address - Street 1:1040 WESTWOOD RD
Mailing Address - Street 2:
Mailing Address - City:WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11598-1125
Mailing Address - Country:US
Mailing Address - Phone:516-343-8802
Mailing Address - Fax:
Practice Address - Street 1:1111 AMSTERDAM AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-1716
Practice Address - Country:US
Practice Address - Phone:212-523-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-12
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10006786363LP0808X
NY309303363LA2200X
WAAP61425969363LP0808X
MT213628363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health