Healthcare Provider Details

I. General information

NPI: 1912794108
Provider Name (Legal Business Name): ASIA JAYLEEN LANDAVERDE MHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2025
Last Update Date: 04/22/2025
Certification Date: 04/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

579 COURTLANDT AVENUE
BRONX NY
10451
US

IV. Provider business mailing address

3856 BRONX BLVD APT 7A
BRONX NY
10467-5213
US

V. Phone/Fax

Practice location:
  • Phone: 718-485-2100
  • Fax:
Mailing address:
  • Phone: 646-609-0656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: