Basic Information
| Provider Information | |||||||||
| NPI: | 1033705538 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERNANDEZ | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | ELIZA | ||||||||
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| Credential: | MHC-LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1662 CORNELIA ST | ||||||||
| Address2: | |||||||||
| City: | RIDGEWOOD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113854723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6462501160 | ||||||||
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| Practice Location | |||||||||
| Address1: | 19 UNION SQ W FL 7 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100033304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2126279600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2020 | ||||||||
| LastUpdateDate: | 12/18/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 100455-01 | NY | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.