Provider Demographics
NPI:1497489694
Name:BLYTHER-TYME, JAQUELA DANIELLE
Entity Type:Individual
Prefix:MRS
First Name:JAQUELA
Middle Name:DANIELLE
Last Name:BLYTHER-TYME
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:JAQUELA
Other - Middle Name:DANIELLE
Other - Last Name:BLYTHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:191 E MARSHALL ST
Mailing Address - Street 2:
Mailing Address - City:HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11550-7421
Mailing Address - Country:US
Mailing Address - Phone:516-439-2036
Mailing Address - Fax:
Practice Address - Street 1:191 E MARSHALL ST
Practice Address - Street 2:
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550-7421
Practice Address - Country:US
Practice Address - Phone:516-439-2036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY115152104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker