Provider Demographics
NPI:1346380276
Name:REARDON, JENNIFER THEO (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:THEO
Last Name:REARDON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 LAWRENCE AVE
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-1019
Mailing Address - Country:US
Mailing Address - Phone:631-741-8896
Mailing Address - Fax:
Practice Address - Street 1:191 BROADWAY
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-2790
Practice Address - Country:US
Practice Address - Phone:631-264-0058
Practice Address - Fax:631-264-0056
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0813361041C0700X
NY0720121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical