Basic Information
| Provider Information | |||||||||
| NPI: | 1578756441 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RAPKE | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5824 WIDEWATERS PKWY | ||||||||
| Address2: | |||||||||
| City: | EAST SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130573072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152513105 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5496 E TAFT RD | ||||||||
| Address2: | |||||||||
| City: | N SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132123784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3155526700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2007 | ||||||||
| LastUpdateDate: | 11/01/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 019669 | NY | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 47037660631 | 05 | NE | MEDICAID | 03545439 | 05 | NY | MEDICAID |