Provider Demographics
NPI:1013191998
Name:FILLER, JACALYN (LCSW)
Entity Type:Individual
Prefix:
First Name:JACALYN
Middle Name:
Last Name:FILLER
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 1:1651 3RD AVE RM 201
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-3679
Mailing Address - Country:US
Mailing Address - Phone:212-831-5127
Mailing Address - Fax:
Practice Address - Street 1:1651 3RD AVE RM 201
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-3679
Practice Address - Country:US
Practice Address - Phone:212-831-5127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-27
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY730448571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
A300047835Medicare PIN