MEDICARE: MS. JACQUELINE S YATES L.M.S.W., C.A.S.A.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	4065	NY
2	104100000X	Social Worker	074090	NY

General Provider Information

NPI Number	:	1134280050
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JACQUELINE S YATES L.M.S.W., C.A.S.A.C.

Provider Business Mailing Address
First Line	:	1463 FLATBUSH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11210-2428
Country	:	US
Telephone Number	:	718-951-9009
Fax Number	:	718-951-9719

Provider Business Practice Location Address
First Line	:	1463 FLATBUSH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11210-2428
Country	:	US
Telephone Number	:	718-951-9009
Fax Number	:	718-951-9719

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/13/2006
Last Update Date	:	08/01/2011

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