Provider Demographics
NPI:1851453682
Name:MERMELSTEIN, JEFFREY JAY (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:JAY
Last Name:MERMELSTEIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 RIVERSIDE DRIVE
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905-4511
Mailing Address - Country:US
Mailing Address - Phone:607-772-1766
Mailing Address - Fax:607-772-2091
Practice Address - Street 1:46 RIVERSIDE DRIVE
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-4511
Practice Address - Country:US
Practice Address - Phone:607-772-1766
Practice Address - Fax:607-772-2091
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006830103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
54869BMedicare ID - Type Unspecified