Healthcare Provider Details

I. General information

NPI: 1962321125
Provider Name (Legal Business Name): JELISE NIMMONS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3375 PARK AVE STE 2005
WANTAGH NY
11793-3712
US

IV. Provider business mailing address

3375 PARK AVE STE 2005
WANTAGH NY
11793-3712
US

V. Phone/Fax

Practice location:
  • Phone: 516-350-8564
  • Fax: 516-874-2477
Mailing address:
  • Phone: 516-350-8564
  • Fax: 516-874-2477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: