Provider Demographics
NPI:1407066178
Name:TEITELBAUM, JEAN HUDSON (LCSW-R)
Entity Type:Individual
Prefix:MS
First Name:JEAN
Middle Name:HUDSON
Last Name:TEITELBAUM
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-3444
Mailing Address - Country:US
Mailing Address - Phone:607-379-4191
Mailing Address - Fax:607-272-9454
Practice Address - Street 1:103 W SENECA ST STE 303A
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-4145
Practice Address - Country:US
Practice Address - Phone:607-379-4191
Practice Address - Fax:607-272-9454
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRO37527-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical