Provider Demographics
NPI:1114439502
Name:TAVERAS, JEANNETTE
Entity Type:Individual
Prefix:MS
First Name:JEANNETTE
Middle Name:
Last Name:TAVERAS
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 1:9411 34TH RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-6036
Mailing Address - Country:US
Mailing Address - Phone:718-808-5605
Mailing Address - Fax:
Practice Address - Street 1:9114 MERRICK BLVD FL 6
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-5247
Practice Address - Country:US
Practice Address - Phone:718-808-5605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-25
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY521485076OtherNEW YORK STATE ID