Basic Information
| Provider Information | |||||||||
| NPI: | 1467839258 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CACKOWSKI | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2570 ROUTE 9W STE 10 | ||||||||
| Address2: | |||||||||
| City: | CORNWALL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125181370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452203100 | ||||||||
| FaxNumber: | 8455342940 | ||||||||
| Practice Location | |||||||||
| Address1: | 35 FELTERS RD | ||||||||
| Address2: | |||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072011200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2015 | ||||||||
| LastUpdateDate: | 10/30/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 296479 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.