Provider Demographics
NPI:1922833326
Name:O'DONNELL, JENNA
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:O'DONNELL
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 1:2393 GLOVER RD
Mailing Address - Street 2:
Mailing Address - City:MARCELLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13108-9725
Mailing Address - Country:US
Mailing Address - Phone:607-329-3188
Mailing Address - Fax:
Practice Address - Street 1:2393 GLOVER RD
Practice Address - Street 2:
Practice Address - City:MARCELLUS
Practice Address - State:NY
Practice Address - Zip Code:13108-9725
Practice Address - Country:US
Practice Address - Phone:607-329-3188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-04
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF354313-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily