Provider Demographics
NPI:1184846818
Name:BACON, JEAN LAROYCE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEAN
Middle Name:LAROYCE
Last Name:BACON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 FIRE ROAD DR
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-3947
Mailing Address - Country:US
Mailing Address - Phone:631-834-0388
Mailing Address - Fax:631-593-5472
Practice Address - Street 1:83 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8305
Practice Address - Country:US
Practice Address - Phone:631-666-5067
Practice Address - Fax:631-593-5472
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045056-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02896748Medicaid
NYA400010901OtherMEDICARE PTAN