Provider Demographics
NPI:1437749140
Name:WHITE, JAY BRANDON WILSON (MHC-I)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:BRANDON WILSON
Last Name:WHITE
Suffix:
Gender:M
Credentials:MHC-I
Other - Prefix:
Other - First Name:JASON
Other - Middle Name:
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:430 W 125TH ST APT 18D
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-4254
Mailing Address - Country:US
Mailing Address - Phone:347-586-3969
Mailing Address - Fax:
Practice Address - Street 1:291 BROADWAY RM 1002
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10007-1883
Practice Address - Country:US
Practice Address - Phone:917-873-1022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-26
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health