Provider Demographics
NPI:1942723523
Name:BRISTOW, JAHNE
Entity type:Individual
Prefix:
First Name:JAHNE
Middle Name:
Last Name:BRISTOW
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 1:108 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:LEWES
Mailing Address - State:DE
Mailing Address - Zip Code:19958-8925
Mailing Address - Country:US
Mailing Address - Phone:845-546-1550
Mailing Address - Fax:
Practice Address - Street 1:18947 JOHN J WILLIAMS HWY UNIT 301
Practice Address - Street 2:
Practice Address - City:REHOBOTH BEACH
Practice Address - State:DE
Practice Address - Zip Code:19971-4477
Practice Address - Country:US
Practice Address - Phone:302-645-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-25
Last Update Date:2025-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY104211223G0001X
NMDD49551223G0001X
PADS0440001223G0001X
390200000X
DE00115831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program