Provider Demographics
NPI:1447551585
Name:LEVY, JACQUELINE I
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:I
Last Name:LEVY
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:JACKIE
Other - Middle Name:I
Other - Last Name:FRIED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6605 BOOTH ST
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-4633
Mailing Address - Country:US
Mailing Address - Phone:917-612-2497
Mailing Address - Fax:718-459-6325
Practice Address - Street 1:6605 BOOTH ST
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-4633
Practice Address - Country:US
Practice Address - Phone:917-612-2497
Practice Address - Fax:718-459-6325
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-05
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY460073235500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235500000XSpeech, Language and Hearing Service ProvidersSpecialist/Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY930546695OtherGHI