Provider Demographics
NPI:1437170222
Name:KING, JEANETTE E (LMSW)
Entity Type:Individual
Prefix:MS
First Name:JEANETTE
Middle Name:E
Last Name:KING
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 629
Mailing Address - Street 2:
Mailing Address - City:WURTSBORO
Mailing Address - State:NY
Mailing Address - Zip Code:12790-0629
Mailing Address - Country:US
Mailing Address - Phone:845-888-0132
Mailing Address - Fax:
Practice Address - Street 1:6 WIERK AVE
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:NY
Practice Address - Zip Code:12754-2117
Practice Address - Country:US
Practice Address - Phone:845-295-4118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
NY075613-11041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00398370Medicaid