Individual
JONATHAN REVAI FENTON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CPSS
Contact information
Practice address
624 ELIZABETH ST, UTICA, NY 13501-2413
(315) 939-3176
Mailing address
624 ELIZABETH ST, UTICA, NY 13501-2413
(315) 939-3176
Taxonomy
Speciality
Code
Description
License number
State
175T00000X
Peer Specialist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
NYCPS-2152
NYS PEER SUPPORT SPECIALIST
NY
Enumeration date
12/06/2022
Last updated
12/06/2022
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