Provider Demographics
NPI:1477818797
Name:VIDALON, JENNIFER LYNN (LMSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:VIDALON
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 1:3602 14TH ST
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11106-4704
Mailing Address - Country:US
Mailing Address - Phone:718-392-2510
Mailing Address - Fax:718-392-2637
Practice Address - Street 1:3602 14TH ST
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11106-4704
Practice Address - Country:US
Practice Address - Phone:718-392-2510
Practice Address - Fax:718-392-2637
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-12
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0805381041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool