MEDICARE: JACQUELINE GATHERS LMSW

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	104100000X	Social Worker	10974	NY

General Provider Information

NPI Number	:	1366154338
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE GATHERS LMSW

Provider Business Mailing Address
First Line	:	1870A STORY AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10473-3240
Country	:	US
Telephone Number	:	718-828-7123
Fax Number	:

Provider Business Practice Location Address
First Line	:	2425 WESTCHESTER AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10461-3540
Country	:	US
Telephone Number	:	718-430-1313
Fax Number	:	929-448-2389

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

Provider Enumeration Date	:	12/21/2022
Last Update Date	:	12/21/2022

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