Provider Demographics
NPI:1871710962
Name:WHITE-GARMAN, JACQUELYN LEE (LCSW)
Entity type:Individual
Prefix:MS
First Name:JACQUELYN
Middle Name:LEE
Last Name:WHITE-GARMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:JACQUELYN
Other - Middle Name:LEE
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:312 TITUSVILLE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12603-2937
Mailing Address - Country:US
Mailing Address - Phone:845-518-5387
Mailing Address - Fax:877-335-8767
Practice Address - Street 1:312 TITUSVILLE RD
Practice Address - Street 2:SUITE A
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12603-2937
Practice Address - Country:US
Practice Address - Phone:845-518-5387
Practice Address - Fax:877-335-8767
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR033564-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN9L38Medicare ID - Type UnspecifiedPROVIDER NUMBER