Provider Demographics
NPI:1134493364
Name:SACKETT, JENNIFER M (LCSW-R)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:SACKETT
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 SOUND BEACH AVE
Mailing Address - Street 2:
Mailing Address - City:BAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11709-2325
Mailing Address - Country:US
Mailing Address - Phone:516-448-4525
Mailing Address - Fax:
Practice Address - Street 1:1157 WILLIS AVE STE 6
Practice Address - Street 2:
Practice Address - City:ALBERTSON
Practice Address - State:NY
Practice Address - Zip Code:11507-1219
Practice Address - Country:US
Practice Address - Phone:516-448-4525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-06
Last Update Date:2018-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR079279-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical