Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1041C0700X | Clinical Social Worker | 078459 | NY |
NPI | 1003177577 |
---|---|
Provider Name | Jacqueline Johnson |
First Address | Newburgh, NY 12550-2800 |
Second Address | Newburgh, NY 12550-2800 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/05/2012 |
Last Update Date | 31/05/2012 |