Provider Demographics
NPI:1689741233
Name:BRENNAN, JACQUELINE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:
Last Name:BRENNAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15901 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11358-1018
Mailing Address - Country:US
Mailing Address - Phone:718-767-6245
Mailing Address - Fax:718-767-6245
Practice Address - Street 1:2350 WATERS EDGE DR
Practice Address - Street 2:SUITE F
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11360-2232
Practice Address - Country:US
Practice Address - Phone:718-767-6245
Practice Address - Fax:718-767-6245
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPR00859811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY132994OtherVALUE OPTIONS
NY7402648OtherGHI
NY04011Medicare ID - Type Unspecified