Healthcare Provider Details

I. General information

NPI: 1952406282
Provider Name (Legal Business Name): JACQUELYN RUTH SULLIVAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 07/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 MAIN STREET SUITE B
SIDNEY NY
13838
US

IV. Provider business mailing address

PO BOX 1046 ATTN: SALLY FOLLETT-BILLING SERVICES
NORWICH NY
13815
US

V. Phone/Fax

Practice location:
  • Phone: 607-563-4080
  • Fax: 607-336-7326
Mailing address:
  • Phone: 607-334-5010
  • Fax: 607-336-7326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number071014
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: