Healthcare Provider Details

I. General information

NPI: 1659659381
Provider Name (Legal Business Name): JACKLYN BYSTRITSKY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2011
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 SAINT MARKS PL
NEW YORK NY
10003-7902
US

IV. Provider business mailing address

28 BAITING PLACE RD STE B
FARMINGDALE NY
11735-6233
US

V. Phone/Fax

Practice location:
  • Phone: 212-982-3470
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number083806-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC06239600
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLICSW124471
License Number StateMA
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number084563
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: