Healthcare Provider Details

I. General information

NPI: 1770779365
Provider Name (Legal Business Name): JEANINE JEUDY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2007
Last Update Date: 09/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

189 MONTAGUE ST SUITE 436
BROOKLYN NY
11201-3610
US

IV. Provider business mailing address

189 MONTAGUE ST SUITE 418
BROOKLYN NY
11201-3610
US

V. Phone/Fax

Practice location:
  • Phone: 718-875-7510
  • Fax: 718-643-3455
Mailing address:
  • Phone: 718-875-5625
  • Fax: 718-875-6876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number075250-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: