Provider Demographics
NPI:1851521371
Name:WOOD, JENNIFER LISA (LMSW)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:LISA
Last Name:WOOD
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 EAGLE LN
Mailing Address - Street 2:
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11788-1209
Mailing Address - Country:US
Mailing Address - Phone:631-921-1962
Mailing Address - Fax:
Practice Address - Street 1:2233 NESCONSET HWY
Practice Address - Street 2:SUITE 104
Practice Address - City:LAKE GROVE
Practice Address - State:NY
Practice Address - Zip Code:11755-1000
Practice Address - Country:US
Practice Address - Phone:631-737-5559
Practice Address - Fax:631-737-0001
Is Sole Proprietor?:No
Enumeration Date:2009-07-17
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP71801104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP71801OtherLMSW LICENSE