=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720733918
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACK ALBERT MCENROE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2022
-----------------------------------------------------
Last Update Date | 12/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 173 WINDWATCH DR
-----------------------------------------------------
City | HAUPPAUGE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11788-3353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-672-5771
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 70 N WOODHULL RD APT 1
-----------------------------------------------------
City | HUNTINGTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11743-2858
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-330-9753
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------