Basic Information
| Provider Information | |||||||||
| NPI: | 1710202544 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DONOVAN | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9 CAREY RD | ||||||||
| Address2: | |||||||||
| City: | QUEENSBURY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128047880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187610300 | ||||||||
| FaxNumber: | 5188242388 | ||||||||
| Practice Location | |||||||||
| Address1: | 152 UPPER SHERMAN AVE | ||||||||
| Address2: | |||||||||
| City: | QUEENSBURY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128042746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187610300 | ||||||||
| FaxNumber: | 5188242390 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2010 | ||||||||
| LastUpdateDate: | 04/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 270181 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 03699290 | 05 | NY | MEDICAID |