Provider Demographics
NPI:1528587078
Name:WITMER, JACLYN LOPEZ (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JACLYN
Middle Name:LOPEZ
Last Name:WITMER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 IRVING PL FL 6
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-2237
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:67 IRVING PL FL 6
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-2237
Practice Address - Country:US
Practice Address - Phone:908-403-8906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-15
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022762101YM0800X, 103T00000X, 103TC0700X
DCPSY1001268103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologist