Provider Demographics
NPI:1417399395
Name:WOOD, JACQUELYN ARIEL
Entity Type:Individual
Prefix:MS
First Name:JACQUELYN
Middle Name:ARIEL
Last Name:WOOD
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 1:829 DOUGHTY AVE
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN SQUARE
Mailing Address - State:NY
Mailing Address - Zip Code:11010-3215
Mailing Address - Country:US
Mailing Address - Phone:516-445-8396
Mailing Address - Fax:
Practice Address - Street 1:829 DOUGHTY AVE
Practice Address - Street 2:
Practice Address - City:FRANKLIN SQUARE
Practice Address - State:NY
Practice Address - Zip Code:11010-3215
Practice Address - Country:US
Practice Address - Phone:516-445-8396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-22
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY251B00000X, 252Y00000X
251C00000X, 251S00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No251B00000XAgenciesCase Management
No252Y00000XAgenciesEarly Intervention Provider Agency
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251S00000XAgenciesCommunity/Behavioral Health