Provider Demographics
NPI:1265677066
Name:PERCIAVALLE, JENNIFER (LCSW, CASAC-G)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PERCIAVALLE
Suffix:
Gender:F
Credentials:LCSW, CASAC-G
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 INDIAN HEAD RD
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-2298
Mailing Address - Country:US
Mailing Address - Phone:631-543-6200
Mailing Address - Fax:
Practice Address - Street 1:155 INDIAN HEAD RD
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725
Practice Address - Country:US
Practice Address - Phone:631-543-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-08
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY28504101YA0400X
NY0876381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)