Provider Demographics
NPI:1285217794
Name:MCCONLOGUE, JARED
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:MCCONLOGUE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 POND LN
Mailing Address - Street 2:
Mailing Address - City:LEVITTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11756-1149
Mailing Address - Country:US
Mailing Address - Phone:516-796-8485
Mailing Address - Fax:
Practice Address - Street 1:70 POND LN
Practice Address - Street 2:
Practice Address - City:LEVITTOWN
Practice Address - State:NY
Practice Address - Zip Code:11756-1149
Practice Address - Country:US
Practice Address - Phone:516-796-8485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-03
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYBACB474504103K00000X, 106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Single Specialty