Provider Demographics
NPI:1609326206
Name:JENNIFER KELSCH LICENSED CLINICAL SOCIAL WORKER PC
Entity Type:Organization
Organization Name:JENNIFER KELSCH LICENSED CLINICAL SOCIAL WORKER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:KELSCH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-R
Authorized Official - Phone:631-875-3549
Mailing Address - Street 1:991 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-1608
Mailing Address - Country:US
Mailing Address - Phone:631-875-3549
Mailing Address - Fax:631-588-8900
Practice Address - Street 1:991 MAIN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-1608
Practice Address - Country:US
Practice Address - Phone:631-875-3549
Practice Address - Fax:631-588-8900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-06
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0776921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
A400063881OtherMEDICARE NUMBER