Basic Information
| Provider Information | |||||||||
| NPI: | 1679783617 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LO | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23 INGRAHAM ST APT 1R | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112063532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2126279600 | ||||||||
| FaxNumber: | 2126274040 | ||||||||
| Practice Location | |||||||||
| Address1: | 19 UNION SQ W | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100033304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2126279600 | ||||||||
| FaxNumber: | 2126274040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 01/16/2014 | ||||||||
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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 | 261QC1500X | 074752 | NY | Y | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
ID Information
| ID | Type | State | Issuer | Description | 074752 | 01 | NY | LMSW LICENSE | OTHER |