Provider Demographics
NPI:1003126046
Name:KINGSBORO PSYCHIATRIC CENTER
Entity Type:Organization
Organization Name:KINGSBORO PSYCHIATRIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT PSYCHIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MAGALIE
Authorized Official - Middle Name:ST LOT
Authorized Official - Last Name:JACQUES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-221-7053
Mailing Address - Street 1:31 BRIDGEWATER CT
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08527-4030
Mailing Address - Country:US
Mailing Address - Phone:732-886-3759
Mailing Address - Fax:
Practice Address - Street 1:681 CLARKSON AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-2125
Practice Address - Country:US
Practice Address - Phone:718-221-7053
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-08
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP25101283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital