Provider Demographics
NPI:1043590730
Name:MERULLA, JACKQUELINE ANNE (LCSW-R)
Entity Type:Individual
Prefix:
First Name:JACKQUELINE
Middle Name:ANNE
Last Name:MERULLA
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:JACKQUELINE
Other - Middle Name:MERULLA
Other - Last Name:BRAMHALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:404 OAK STREET STREET
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-2997
Mailing Address - Country:US
Mailing Address - Phone:315-703-0168
Mailing Address - Fax:315-299-2530
Practice Address - Street 1:404 OAK STREET STREET
Practice Address - Street 2:SUITE 200
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-2997
Practice Address - Country:US
Practice Address - Phone:315-703-0168
Practice Address - Fax:315-299-2530
Is Sole Proprietor?:No
Enumeration Date:2011-08-25
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY083923-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical