MEDICARE: MRS. JENNIFER LYNNE MANDATO TRUCIOS CASAC-T, CRPA-P

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	37240	NY
2	104100000X	Social Worker		NY

General Provider Information

NPI Number	:	1538731369
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JENNIFER LYNNE MANDATO TRUCIOS CASAC-T, CRPA-P

Provider Business Mailing Address
First Line	:	6465 TRANSIT ROAD
Second Line	:
City	:	EAST AMHERST
State	:	NY
Zip	:	14051
Country	:	US
Telephone Number	:	716-588-4292
Fax Number	:

Provider Business Practice Location Address
First Line	:	CAMELOT, 460 BRIELLE AVENUE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10309
Country	:	US
Telephone Number	:	134-792-3137
Fax Number	:

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

Provider Enumeration Date	:	07/12/2021
Last Update Date	:	01/06/2026

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