Provider Demographics
NPI:1447354931
Name:ANDERSON, JACQUELINE CONNELL (LCSW)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:CONNELL
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:590 GREENE AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11216-1200
Mailing Address - Country:US
Mailing Address - Phone:347-217-0929
Mailing Address - Fax:
Practice Address - Street 1:590 GREENE AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11216-1200
Practice Address - Country:US
Practice Address - Phone:347-217-0929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR027545-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00244931Medicaid
NYS36001Medicare UPIN
NY00244931Medicaid