Healthcare Provider Details

I. General information

NPI: 1710439476
Provider Name (Legal Business Name): JEFFERY EDWARDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2016
Last Update Date: 10/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 W 35TH ST 2ND FLOOR
NEW YORK NY
10001-1701
US

IV. Provider business mailing address

311 W 35TH ST 2ND FLOOR
NEW YORK NY
10001-1701
US

V. Phone/Fax

Practice location:
  • Phone: 212-736-5900
  • Fax: 212-643-1441
Mailing address:
  • Phone: 212-736-5900
  • Fax: 212-643-1441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number24881
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: