Provider Demographics
NPI:1750056792
Name:SALCEDO, JERRY
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:SALCEDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:466 MAIN ST # LL20
Mailing Address - Street 2:
Mailing Address - City:NEW ROCHELLE
Mailing Address - State:NY
Mailing Address - Zip Code:10801-6431
Mailing Address - Country:US
Mailing Address - Phone:347-730-2582
Mailing Address - Fax:
Practice Address - Street 1:2840 BAILEY AVE APT B21
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-7239
Practice Address - Country:US
Practice Address - Phone:347-730-2582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-11
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician