Provider Demographics
NPI:1689712416
Name:WASSERSTEIN, JEANETTE (PHD)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:
Last Name:WASSERSTEIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1160 FIFTH AVENUE
Mailing Address - Street 2:SUITE 112
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029
Mailing Address - Country:US
Mailing Address - Phone:212-369-7228
Mailing Address - Fax:212-799-9653
Practice Address - Street 1:1160 FIFTH AVENUE
Practice Address - Street 2:SUITE 112
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029
Practice Address - Country:US
Practice Address - Phone:212-369-7228
Practice Address - Fax:212-799-9653
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2008-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0074571103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV19651Medicare ID - Type Unspecified