Provider Demographics
NPI:1134315740
Name:LIU, JEAN
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:LIU
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 1:5011 COTTAGE LN
Mailing Address - Street 2:
Mailing Address - City:MARCY
Mailing Address - State:NY
Mailing Address - Zip Code:13403-3036
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:44 HOLLAND AVENUE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12229-0001
Practice Address - Country:US
Practice Address - Phone:351-736-8271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2345892084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY234589Medicaid