Provider Demographics
NPI:1235951013
Name:FENNELLY, JEFFREY JOHN (LCSW)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:JOHN
Last Name:FENNELLY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 W 46TH ST APT 3A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10036-3579
Mailing Address - Country:US
Mailing Address - Phone:917-447-7437
Mailing Address - Fax:
Practice Address - Street 1:418 W 46TH ST APT 3A
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10036-3579
Practice Address - Country:US
Practice Address - Phone:917-447-7437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-31
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY073283-011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical