Provider Demographics
NPI:1063820066
Name:JACKLIN, THERESA (LCSW)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:JACKLIN
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 1:600 COMMUNITY DR STE 400
Mailing Address - Street 2:
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-3818
Mailing Address - Country:US
Mailing Address - Phone:646-201-1972
Mailing Address - Fax:
Practice Address - Street 1:8543 250TH ST
Practice Address - Street 2:
Practice Address - City:BELLEROSE
Practice Address - State:NY
Practice Address - Zip Code:11426-2110
Practice Address - Country:US
Practice Address - Phone:646-201-1972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-23
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0882991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical