Healthcare Provider Details

I. General information

NPI: 1124703103
Provider Name (Legal Business Name): JACKQUELIN MARIE GRANT LP-MHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2023
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 W 52ND ST APT 19F
NEW YORK NY
10019-5298
US

IV. Provider business mailing address

510 W 52ND ST APT 19F
NEW YORK NY
10019-5298
US

V. Phone/Fax

Practice location:
  • Phone: 646-284-6394
  • Fax:
Mailing address:
  • Phone: 646-284-6394
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number018541
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: