Basic Information
| Provider Information | |||||||||
| NPI: | 1154766467 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OSBOURNE | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | RENELLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WINCHESTER | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | RENELLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2800 MARCUS AVENUE | ||||||||
| Address2: | |||||||||
| City: | NEW HYDE PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166226000 | ||||||||
| FaxNumber: | 5166222914 | ||||||||
| Practice Location | |||||||||
| Address1: | 3801 NORTH BLVD | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708063825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2253877899 | ||||||||
| FaxNumber: | 2253812579 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2013 | ||||||||
| LastUpdateDate: | 01/18/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 285407 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.