Provider Demographics
NPI:1598423410
Name:IM, JENNIFER (PHD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:IM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 GREENWAY W
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-2227
Mailing Address - Country:US
Mailing Address - Phone:516-551-2455
Mailing Address - Fax:
Practice Address - Street 1:16 W 86TH ST APT 1A
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-3651
Practice Address - Country:US
Practice Address - Phone:212-560-2437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-08
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool