MEDICARE: JENNA ANN WEICK LCSW-R

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	082458	NY
2	1041C0700X	Clinical Social Worker	081638-1	NY

General Provider Information

NPI Number	:	1790084275
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNA ANN WEICK LCSW-R

Provider Business Mailing Address
First Line	:	78 GRASSLANDS CIR
Second Line	:
City	:	MOUNT SINAI
State	:	NY
Zip	:	11766-1858
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	21 MAPLE AVE
Second Line	:
City	:	BAY SHORE
State	:	NY
Zip	:	11706-8752
Country	:	US
Telephone Number	:	631-213-1975
Fax Number	:

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

Provider Enumeration Date	:	03/23/2011
Last Update Date	:	08/07/2025

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