Provider Demographics
NPI:1346889912
Name:DITTUS, JEFFREY WARD
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:WARD
Last Name:DITTUS
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 1:1216 BAY ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-3169
Mailing Address - Country:US
Mailing Address - Phone:718-982-4740
Mailing Address - Fax:
Practice Address - Street 1:1216 BAY ST
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3169
Practice Address - Country:US
Practice Address - Phone:718-982-4740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-31
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY072561104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker