MEDICARE: MRS. JEANNETTE A SUCRE 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	090988-01	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	136167177	OTHER	NY	FIDELIS

General Provider Information

NPI Number	:	1285765784
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JEANNETTE A SUCRE LCSW

Provider Business Mailing Address
First Line	:	35 HAMILTON PL APT 101
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10031-6813
Country	:	US
Telephone Number	:	212-933-1865
Fax Number	:	212-933-1865

Provider Business Practice Location Address
First Line	:	35 HAMILTON PL APT 101
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10031-6813
Country	:	US
Telephone Number	:	212-933-1865
Fax Number	:	212-933-1865

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

Provider Enumeration Date	:	03/08/2007
Last Update Date	:	02/22/2022

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