Provider Demographics
NPI:1548618077
Name:SALOMON, JACK
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:SALOMON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:YAAKOV
Other - Middle Name:
Other - Last Name:SALOMON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:615 AVENUE L
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-5121
Mailing Address - Country:US
Mailing Address - Phone:718-375-0755
Mailing Address - Fax:
Practice Address - Street 1:615 AVENUE L
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-5121
Practice Address - Country:US
Practice Address - Phone:718-375-0755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-25
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0185491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical