Provider Demographics
NPI:1346764610
Name:CRAIG, JENELLE ANNTONETTE
Entity Type:Individual
Prefix:
First Name:JENELLE
Middle Name:ANNTONETTE
Last Name:CRAIG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 E 14TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-3979
Mailing Address - Country:US
Mailing Address - Phone:718-769-2698
Mailing Address - Fax:
Practice Address - Street 1:9 PAERDEGAT 12TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-4119
Practice Address - Country:US
Practice Address - Phone:347-221-8476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-28
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1152511171103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool