Provider Demographics
NPI:1629219001
Name:JEAN-ETIENNE, HOSANA CRYSTAL (LMSW)
Entity Type:Individual
Prefix:
First Name:HOSANA
Middle Name:CRYSTAL
Last Name:JEAN-ETIENNE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:HOSANA
Other - Middle Name:CRYSTAL
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:79 MIDDLEVILLE ROAD
Mailing Address - Street 2:VA MEDICAL CENTER NORTHPORT
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-4715
Mailing Address - Country:US
Mailing Address - Phone:631-261-4400
Mailing Address - Fax:
Practice Address - Street 1:79 MIDDLEVILLE RD
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-2200
Practice Address - Country:US
Practice Address - Phone:631-261-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-16
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY077080104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker