=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013787159
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JADYN NICOLE VARGAS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2024
-----------------------------------------------------
Last Update Date | 01/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 263 ROUTE 17K STE 107A
-----------------------------------------------------
City | NEWBURGH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12550-8345
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-200-9230
-----------------------------------------------------
Fax | 845-662-6504
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14 CASE CT
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10950-4942
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-537-0023
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 121488-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------