Provider Demographics
NPI:1083207427
Name:ACEVEDO, JILIAN
Entity Type:Individual
Prefix:
First Name:JILIAN
Middle Name:
Last Name:ACEVEDO
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 1:712 KIMBALL AVE
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10704-1530
Mailing Address - Country:US
Mailing Address - Phone:917-415-1957
Mailing Address - Fax:
Practice Address - Street 1:689 MAMARONECK AVE
Practice Address - Street 2:
Practice Address - City:MAMARONECK
Practice Address - State:NY
Practice Address - Zip Code:10543-5910
Practice Address - Country:US
Practice Address - Phone:914-539-1499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-17
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY107907-011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY107907-01Medicaid