Basic Information
| Provider Information | |||||||||
| NPI: | 1285741975 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOUT-ROSS | ||||||||
| FirstName: | JACQUELYN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROSS | ||||||||
| OtherFirstName: | JACQUELYN | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2215 BURDETT AVE | ||||||||
| Address2: | BEHAVIORAL HEALTH DEPT | ||||||||
| City: | TROY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121802466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182713300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2215 BURDETT AVE | ||||||||
| Address2: | BEHAVIORAL HEALTH DEPT | ||||||||
| City: | TROY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121802466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182713300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 12/10/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 070025 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.