Provider Demographics
NPI:1235209743
Name:KOGAN, JEROME H (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:H
Last Name:KOGAN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 E 77TH ST
Mailing Address - Street 2:SUITE 324
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-1851
Mailing Address - Country:US
Mailing Address - Phone:212-434-2961
Mailing Address - Fax:212-434-3306
Practice Address - Street 1:7 CLIFF WAY
Practice Address - Street 2:
Practice Address - City:LARCHMONT
Practice Address - State:NY
Practice Address - Zip Code:10538-2505
Practice Address - Country:US
Practice Address - Phone:914-473-9615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0115471103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV805Z1Medicare ID - Type Unspecified