Basic Information
| Provider Information | |||||||||
| NPI: | 1437882271 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MYERS | ||||||||
| FirstName: | JACQUELYN | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | MHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1753 SANDRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | ALDEN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140049744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168609696 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5360 GENESEE ST | ||||||||
| Address2: | |||||||||
| City: | BOWMANSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140261044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168956700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2022 | ||||||||
| LastUpdateDate: | 07/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YS0200X | NY | N | Behavioral Health & Social Service Providers | Counselor | School | 101YM0800X | NY | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.