Provider Demographics
NPI:1760659189
Name:GRABON, JACK
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:GRABON
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 1:6128 MADISON ST APT 1C
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-4016
Mailing Address - Country:US
Mailing Address - Phone:718-777-8858
Mailing Address - Fax:
Practice Address - Street 1:6128 MADISON ST APT 1C
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-4016
Practice Address - Country:US
Practice Address - Phone:718-777-8858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-14
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY074132-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker