Provider Demographics
NPI:1245398197
Name:DE SANTIS, JACK (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:
Last Name:DE SANTIS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 RIDGEFIELD ROAD
Mailing Address - Street 2:
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11788-2312
Mailing Address - Country:US
Mailing Address - Phone:631-361-8865
Mailing Address - Fax:631-361-8865
Practice Address - Street 1:368 VETERANS MEMORIAL HIGHWAY
Practice Address - Street 2:SUITE #1
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-4315
Practice Address - Country:US
Practice Address - Phone:631-543-8779
Practice Address - Fax:631-361-8865
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPR00475811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN01491Medicare ID - Type Unspecified
R45846Medicare UPIN