Provider Demographics
NPI:1417569252
Name:TANNENBAUM, JESSICA LAUREN (LCSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LAUREN
Last Name:TANNENBAUM
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 1:6500 JERICHO TURNPIKE SUITE 217
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725
Mailing Address - Country:US
Mailing Address - Phone:631-543-8877
Mailing Address - Fax:
Practice Address - Street 1:6500 JERICHO TPKE STE 217
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-2907
Practice Address - Country:US
Practice Address - Phone:516-298-5981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-22
Last Update Date:2023-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY106511104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker