Provider Demographics
NPI:1174910301
Name:MCLEOD, JENNIFER MONIQUE (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MONIQUE
Last Name:MCLEOD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56-45 MAIN STREET
Mailing Address - Street 2:QUEENS
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:11355
Mailing Address - Country:US
Mailing Address - Phone:347-480-1200
Mailing Address - Fax:
Practice Address - Street 1:56-45 MAIN ST
Practice Address - Street 2:
Practice Address - City:QUEENS
Practice Address - State:NY
Practice Address - Zip Code:11355-5045
Practice Address - Country:US
Practice Address - Phone:347-480-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-26
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY293298207R00000X, 207RC0000X, 207RA0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0001XAllopathic & Osteopathic PhysiciansInternal MedicineAdvanced Heart Failure and Transplant CardiologyGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAJM3232267556Medicaid