Provider Demographics
NPI:1164870952
Name:KHAWAJA, JEWEL (CASAC)
Entity Type:Individual
Prefix:
First Name:JEWEL
Middle Name:
Last Name:KHAWAJA
Suffix:
Gender:M
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 EXECUTIVE BLVD
Mailing Address - Street 2:SUITE D
Mailing Address - City:VALLEY COTTAGE
Mailing Address - State:NY
Mailing Address - Zip Code:10989-2038
Mailing Address - Country:US
Mailing Address - Phone:845-362-3904
Mailing Address - Fax:
Practice Address - Street 1:706 EXECUTIVE BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:VALLEY COTTAGE
Practice Address - State:NY
Practice Address - Zip Code:10989-2038
Practice Address - Country:US
Practice Address - Phone:845-362-3904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-02
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY26596171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator