Provider Demographics
NPI:1144739251
Name:CEVETILLO, JAMIE NICOLE (MASTERS MHC)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:NICOLE
Last Name:CEVETILLO
Suffix:
Gender:F
Credentials:MASTERS MHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601-2388
Mailing Address - Country:US
Mailing Address - Phone:845-486-4192
Mailing Address - Fax:845-486-3690
Practice Address - Street 1:82 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-2388
Practice Address - Country:US
Practice Address - Phone:845-486-4192
Practice Address - Fax:845-486-3690
Is Sole Proprietor?:No
Enumeration Date:2017-09-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP05578101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02997648Medicaid