Provider Demographics
NPI:1659780401
Name:PACHECO, JENNIFER L
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:PACHECO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1116 ELLSWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10465-1413
Mailing Address - Country:US
Mailing Address - Phone:347-852-6555
Mailing Address - Fax:
Practice Address - Street 1:1116 ELLSWORTH AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10465-1413
Practice Address - Country:US
Practice Address - Phone:347-852-6555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-06
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY764809132103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst