Provider Demographics
NPI:1164732897
Name:SANTIAGO, JORGE JR
Entity Type:Individual
Prefix:MR
First Name:JORGE
Middle Name:
Last Name:SANTIAGO
Suffix:JR
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 1:65 N COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:SHOREHAM
Mailing Address - State:NY
Mailing Address - Zip Code:11786-1802
Mailing Address - Country:US
Mailing Address - Phone:631-821-0357
Mailing Address - Fax:
Practice Address - Street 1:65 N COUNTRY RD
Practice Address - Street 2:
Practice Address - City:SHOREHAM
Practice Address - State:NY
Practice Address - Zip Code:11786-1802
Practice Address - Country:US
Practice Address - Phone:631-821-0357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-15
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR-046643-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical