Provider Demographics
NPI:1659038644
Name:TIETJEN, JENNIFER (LMSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:TIETJEN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 CANDEE AVE
Mailing Address - Street 2:
Mailing Address - City:SAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11782-3044
Mailing Address - Country:US
Mailing Address - Phone:631-941-1200
Mailing Address - Fax:
Practice Address - Street 1:33 CANDEE AVE
Practice Address - Street 2:
Practice Address - City:SAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11782-3044
Practice Address - Country:US
Practice Address - Phone:631-941-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-24
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY105318104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker