Provider Demographics
NPI:1679783617
Name:LO, JENNIFER N (LMSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:N
Last Name:LO
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 1:23 INGRAHAM ST APT 1R
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11206-3532
Mailing Address - Country:US
Mailing Address - Phone:212-627-9600
Mailing Address - Fax:212-627-4040
Practice Address - Street 1:19 UNION SQ W
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-3304
Practice Address - Country:US
Practice Address - Phone:212-627-9600
Practice Address - Fax:212-627-4040
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY074752261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY074752OtherLMSW LICENSE