MEDICARE: JERRY S. KATZ LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	R038583	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	R038583	OTHER	NY	STATE LICENSE
2	P1223060	OTHER		OXFORD

General Provider Information

NPI Number	:	1215984125
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERRY S. KATZ LCSW

Provider Business Mailing Address
First Line	:	3429 80TH ST
Second Line	:	APT.52
City	:	JACKSON HEIGHTS
State	:	NY
Zip	:	11372-2705
Country	:	US
Telephone Number	:	917-359-5375
Fax Number	:	718-424-2776

Provider Business Practice Location Address
First Line	:	347 5TH AVE
Second Line	:	RM.1401
City	:	NEW YORK
State	:	NY
Zip	:	10016-5010
Country	:	US
Telephone Number	:	917-359-5375
Fax Number	:	718-424-2776

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/27/2006
Last Update Date	:	07/08/2007

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