Provider Demographics
NPI:1174297865
Name:BURGOS, JENICE (LMSW)
Entity Type:Individual
Prefix:
First Name:JENICE
Middle Name:
Last Name:BURGOS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 GATES AVE APT 1R
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11237-5669
Mailing Address - Country:US
Mailing Address - Phone:347-553-6798
Mailing Address - Fax:
Practice Address - Street 1:760 BROADWAY # 5A206
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206-5383
Practice Address - Country:US
Practice Address - Phone:718-963-5893
Practice Address - Fax:718-630-3138
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-05
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY107043261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY100148153Medicaid