Provider Demographics
NPI:1871304006
Name:MEDINA, JAILENE DIANE (MHC-LP)
Entity type:Individual
Prefix:
First Name:JAILENE
Middle Name:DIANE
Last Name:MEDINA
Suffix:
Gender:F
Credentials:MHC-LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 E 120TH ST APT 2M
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10035-3677
Mailing Address - Country:US
Mailing Address - Phone:917-861-7352
Mailing Address - Fax:
Practice Address - Street 1:55 MAIN ST
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10701-2739
Practice Address - Country:US
Practice Address - Phone:914-327-5588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-16
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP133287101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health