Healthcare Provider Details

I. General information

NPI: 1619247434
Provider Name (Legal Business Name): SHIRLEY MARISOL JARRIN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2012
Last Update Date: 01/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 JEROME AVE
BRONX NY
10467-1052
US

IV. Provider business mailing address

11250 78TH AVE APT: 5G
FOREST HILLS NY
11375-7109
US

V. Phone/Fax

Practice location:
  • Phone: 718-881-7600
  • Fax: 718-515-8057
Mailing address:
  • Phone: 917-568-8352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number076522
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: