Healthcare Provider Details

I. General information

NPI: 1073468799
Provider Name (Legal Business Name): CLEMENTINA JOSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2026
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 BROADWAY
NEW YORK NY
10012-4454
US

IV. Provider business mailing address

8936 86TH ST
WOODHAVEN NY
11421-2507
US

V. Phone/Fax

Practice location:
  • Phone: 347-869-2251
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: