Provider Demographics
NPI:1114560752
Name:RAJU, JERRY
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:RAJU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:832 BRYANT AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-3854
Mailing Address - Country:US
Mailing Address - Phone:516-499-4827
Mailing Address - Fax:
Practice Address - Street 1:1069 HEMPSTEAD TPKE
Practice Address - Street 2:
Practice Address - City:FRANKLIN SQUARE
Practice Address - State:NY
Practice Address - Zip Code:11010-2631
Practice Address - Country:US
Practice Address - Phone:516-865-1146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-28
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician