Provider Demographics
NPI:1477983484
Name:MEDINA, JO
Entity Type:Individual
Prefix:
First Name:JO
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JO ANN
Other - Middle Name:
Other - Last Name:MEDINA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMSW
Mailing Address - Street 1:120 CENTER LN
Mailing Address - Street 2:
Mailing Address - City:LEVITTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11756-1062
Mailing Address - Country:US
Mailing Address - Phone:516-520-8370
Mailing Address - Fax:516-520-6288
Practice Address - Street 1:120 CENTER LN
Practice Address - Street 2:
Practice Address - City:LEVITTOWN
Practice Address - State:NY
Practice Address - Zip Code:11756-1062
Practice Address - Country:US
Practice Address - Phone:516-520-8370
Practice Address - Fax:516-520-6288
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-13
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033491104100000X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool