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NPI Code Detail

MEDICARE: MS. JACLYN MISTRETTA LCSW

MEDICARE: MS. JACLYN MISTRETTA 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
11041C0700XClinical Social Worker091687NY

General Provider Information

NPI Number : 1972234649
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. JACLYN MISTRETTA LCSW
Provider Business Mailing Address
First Line : 37 OCEANIC AVE
Second Line :
City : STATEN ISLAND
State : NY
Zip : 10312-6511
Country : US
Telephone Number : 917-622-0114
Fax Number :
Provider Business Practice Location Address
First Line : 37 OCEANIC AVE
Second Line :
City : STATEN ISLAND
State : NY
Zip : 10312-6511
Country : US
Telephone Number : 917-622-0114
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/22/2022
Last Update Date : 06/22/2022

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