Basic Information
| Provider Information | |||||||||
| NPI: | 1326249699 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GHOLSTON | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | REICHER | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 665 PELHAM PKWY N | ||||||||
| Address2: | SUITE 402 | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104678068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185198326 | ||||||||
| FaxNumber: | 7188818714 | ||||||||
| Practice Location | |||||||||
| Address1: | 665 PELHAM PKWY N | ||||||||
| Address2: | SUITE 402 | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104678068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185198326 | ||||||||
| FaxNumber: | 7188818714 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 057009 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.