=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740703560
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NADINE YVETTE JACKSON CASAC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2017
-----------------------------------------------------
Last Update Date | 07/24/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1751 PARK AVE
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10035-2809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-991-4994
-----------------------------------------------------
Fax | 212-414-1431
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 141 W 128TH ST APT 7
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10027-3027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-657-0063
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 2-11436
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------