Basic Information
| Provider Information | |||||||||
| NPI: | 1346731270 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIMMONS | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | ENITH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SIMMONS | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | ENITH | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 550 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | LINDENHURST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117573110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6319422703 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1841 BRENTWOOD RD | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117174625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6318537300 | ||||||||
| FaxNumber: | 6318537301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2018 | ||||||||
| LastUpdateDate: | 05/26/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 101424 | NY | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.