Provider Demographics
NPI:1760249817
Name:FARIAS, JEANETTE S (MHC-LP)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:S
Last Name:FARIAS
Suffix:
Gender:F
Credentials:MHC-LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4902 QUEENS BLVD
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-4444
Mailing Address - Country:US
Mailing Address - Phone:347-319-6453
Mailing Address - Fax:
Practice Address - Street 1:4902 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-4444
Practice Address - Country:US
Practice Address - Phone:347-319-6453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-05
Last Update Date:2024-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP127108101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health