Provider Demographics
NPI:1881831949
Name:WHALEY GUNDERSEN, JENNIFER DANA (LCSW, CASAC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DANA
Last Name:WHALEY GUNDERSEN
Suffix:
Gender:F
Credentials:LCSW, CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 JOHNSON AVE STE C13
Mailing Address - Street 2:
Mailing Address - City:BOHEMIA
Mailing Address - State:NY
Mailing Address - Zip Code:11716-2674
Mailing Address - Country:US
Mailing Address - Phone:631-960-8575
Mailing Address - Fax:
Practice Address - Street 1:600 JOHNSON AVE STE C13
Practice Address - Street 2:
Practice Address - City:BOHEMIA
Practice Address - State:NY
Practice Address - Zip Code:11716-2674
Practice Address - Country:US
Practice Address - Phone:631-960-8575
Practice Address - Fax:631-315-1090
Is Sole Proprietor?:No
Enumeration Date:2009-01-12
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0775611041C0700X
NY079761-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01781144Medicaid