Healthcare Provider Details

I. General information

NPI: 1083527659
Provider Name (Legal Business Name): JAMIE FASTOV LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 E 23RD ST STE 304
NEW YORK NY
10010-4576
US

IV. Provider business mailing address

77 PARK AVE APT 315
HOBOKEN NJ
07030-7107
US

V. Phone/Fax

Practice location:
  • Phone: 212-906-9038
  • Fax:
Mailing address:
  • Phone: 917-446-1062
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number44SL07556900
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number133171
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: