Basic Information
| Provider Information | |||||||||
| NPI: | 1184781627 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ISDITH | ||||||||
| FirstName: | JORGE | ||||||||
| MiddleName: | E. | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | M.A. M.S. PSYCH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 35-50 85 STREET | ||||||||
| Address2: | APT. #3E | ||||||||
| City: | JACKSON HEIGHTS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184263536 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10470 QUEENS BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | FOREST HILLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113753694 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182756010 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2007 | ||||||||
| LastUpdateDate: | 07/25/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | NY | X | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103TS0200X | NY | X | Behavioral Health & Social Service Providers | Psychologist | School |
No ID Information.