Healthcare Provider Details

I. General information

NPI: 1841787801
Provider Name (Legal Business Name): JENNA RAE MARGOLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2018
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4802 10TH AVE
BROOKLYN NY
11219-2916
US

IV. Provider business mailing address

4802 10TH AVE
BROOKLYN NY
11219-2916
US

V. Phone/Fax

Practice location:
  • Phone: 718-283-6879
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number312645
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: