Healthcare Provider Details

I. General information

NPI: 1861958167
Provider Name (Legal Business Name): JENNIFER NUSSBAUM LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2019
Last Update Date: 04/08/2026
Certification Date: 04/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 WALT WHITMAN RD STE 227W
HUNTINGTON STATION NY
11746-3640
US

IV. Provider business mailing address

32 BEAUMONT DR
MELVILLE NY
11747-3402
US

V. Phone/Fax

Practice location:
  • Phone: 631-988-8109
  • Fax:
Mailing address:
  • Phone: 631-998-8109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number097178-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: