Provider Demographics
NPI:1043086291
Name:RAJA, JACQUELINA
Entity Type:Individual
Prefix:
First Name:JACQUELINA
Middle Name:
Last Name:RAJA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8011 18TH AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214-1705
Mailing Address - Country:US
Mailing Address - Phone:646-517-0708
Mailing Address - Fax:
Practice Address - Street 1:8011 18TH AVE FL 2
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-1705
Practice Address - Country:US
Practice Address - Phone:646-517-0708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-29
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health