Basic Information
| Provider Information | |||||||||
| NPI: | 1407220312 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCMILLIAN | ||||||||
| FirstName: | JAQUAN | ||||||||
| MiddleName: | JALEEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2384 ATLANTIC AVE | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112333402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182726025 | ||||||||
| FaxNumber: | 7189227416 | ||||||||
| Practice Location | |||||||||
| Address1: | 2384 ATLANTIC AVE | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112333402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182726025 | ||||||||
| FaxNumber: | 7189227416 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2015 | ||||||||
| LastUpdateDate: | 11/17/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 0851641 | NY | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 01305004 | 05 | NY | MEDICAID |