Provider Demographics
NPI:1336482223
Name:JACK & JILL DEVELOPMENTAL SERVICES, SLP, OT & PSYCHOLOGY, PLLP
Entity Type:Organization
Organization Name:JACK & JILL DEVELOPMENTAL SERVICES, SLP, OT & PSYCHOLOGY, PLLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:845-292-4134
Mailing Address - Street 1:17 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:NY
Mailing Address - Zip Code:12754-1807
Mailing Address - Country:US
Mailing Address - Phone:845-292-4134
Mailing Address - Fax:845-292-4134
Practice Address - Street 1:17 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:NY
Practice Address - Zip Code:12754-1807
Practice Address - Country:US
Practice Address - Phone:845-292-4134
Practice Address - Fax:845-292-4134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-29
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008719252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency