Provider Demographics
NPI:1922479534
Name:ATHERLY-OLUWA, JACQUELINE (MHC)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:ATHERLY-OLUWA
Suffix:
Gender:F
Credentials:MHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 BURRS LN
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746-6052
Mailing Address - Country:US
Mailing Address - Phone:631-253-3480
Mailing Address - Fax:631-253-3480
Practice Address - Street 1:151 BURRS LN
Practice Address - Street 2:
Practice Address - City:DIX HILLS
Practice Address - State:NY
Practice Address - Zip Code:11746-6052
Practice Address - Country:US
Practice Address - Phone:631-253-3480
Practice Address - Fax:631-253-3480
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-08
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP99119101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health