Provider Demographics
NPI:1518719087
Name:ACEVEDO, JORGE LUIS
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:LUIS
Last Name:ACEVEDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 NIAGARA ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14201-1886
Mailing Address - Country:US
Mailing Address - Phone:716-853-1335
Mailing Address - Fax:716-853-1598
Practice Address - Street 1:430 NIAGARA ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14201-1886
Practice Address - Country:US
Practice Address - Phone:716-853-1335
Practice Address - Fax:716-853-1598
Is Sole Proprietor?:No
Enumeration Date:2024-04-05
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY33728101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)