Healthcare Provider Details

I. General information

NPI: 1487454351
Provider Name (Legal Business Name): JEAN A ANTOINE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2025
Last Update Date: 07/22/2026
Certification Date: 04/25/2026
Deactivation Date: 04/26/2026
Reactivation Date: 07/22/2026

III. Provider practice location address

8854 204TH ST
HOLLIS NY
11423-2206
US

IV. Provider business mailing address

8854 204TH ST
HOLLIS NY
11423-2206
US

V. Phone/Fax

Practice location:
  • Phone: 347-558-3851
  • Fax:
Mailing address:
  • Phone: 347-558-3851
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: