Provider Demographics
NPI:1033705538
Name:HERNANDEZ, JACQUELINE ELIZA (MHC-LP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ELIZA
Last Name:HERNANDEZ
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 1:1662 CORNELIA ST
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-4723
Mailing Address - Country:US
Mailing Address - Phone:646-250-1160
Mailing Address - Fax:
Practice Address - Street 1:19 UNION SQ W FL 7
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-3304
Practice Address - Country:US
Practice Address - Phone:212-627-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-18
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY100455-01101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)