Provider Demographics
NPI:1851956338
Name:LEVY-VINOCUR, JACLYN M (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACLYN
Middle Name:M
Last Name:LEVY-VINOCUR
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:M
Other - Last Name:LEVY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:611 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10012-2608
Mailing Address - Country:US
Mailing Address - Phone:516-447-0733
Mailing Address - Fax:
Practice Address - Street 1:14 VANDERVENTER AVE STE 103
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:NY
Practice Address - Zip Code:11050-3757
Practice Address - Country:US
Practice Address - Phone:516-271-2644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-09
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023209103TB0200X, 103TC0700X, 103TC2200X, 103TF0000X, 103TP2701X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy