Basic Information
| Provider Information | |||||||||
| NPI: | 1801911854 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JUMPER | ||||||||
| FirstName: | KATHRYN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 790 PARK AVE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117434516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314273700 | ||||||||
| FaxNumber: | 6314270287 | ||||||||
| Practice Location | |||||||||
| Address1: | 7555 MAIN ROAD | ||||||||
| Address2: | |||||||||
| City: | MATTITUCK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6312988642 | ||||||||
| FaxNumber: | 6312984869 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 074071 | NY | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 00074071 | 05 | NY | MEDICAID |