Healthcare Provider Details

I. General information

NPI: 1558891044
Provider Name (Legal Business Name): JEAN MARY TAYLOR LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2017
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 LAKE AVE
ROCHESTER NY
14608-1410
US

IV. Provider business mailing address

100 KINGS HWY S
ROCHESTER NY
14617-5504
US

V. Phone/Fax

Practice location:
  • Phone: 585-683-6907
  • Fax: 585-368-6982
Mailing address:
  • Phone: 585-922-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number090376-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: