Provider Demographics
NPI:1164555801
Name:JEROME STREET CLINIC
Entity Type:Organization
Organization Name:JEROME STREET CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPANELLI
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:212-385-3030
Mailing Address - Street 1:971 JEROME ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11207-9252
Mailing Address - Country:US
Mailing Address - Phone:718-272-3300
Mailing Address - Fax:
Practice Address - Street 1:971 JEROME ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11207-9252
Practice Address - Country:US
Practice Address - Phone:718-272-3300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01551404Medicaid
NYW1V323Medicare ID - Type Unspecified