=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447773064
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNA LYNN MCLOUGHLIN LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2017
-----------------------------------------------------
Last Update Date | 07/25/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12520 SUTPHIN BLVD
-----------------------------------------------------
City | JAMAICA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11434-2340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-322-9012
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 132 LEE AVE
-----------------------------------------------------
City | HICKSVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11801-5810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-313-9433
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 080391-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------