Basic Information
| Provider Information | |||||||||
| NPI: | 1962045369 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 PEARL CT | ||||||||
| Address2: | |||||||||
| City: | WEST ISLIP | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117952222 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 770 GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | DEER PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117295750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6313924357 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2019 | ||||||||
| LastUpdateDate: | 10/18/2019 | ||||||||
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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 | 104100000X | 098380 | NY | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.