Provider Demographics
NPI:1932121084
Name:INCLAN, JAIME (PHD)
Entity Type:Individual
Prefix:MR
First Name:JAIME
Middle Name:
Last Name:INCLAN
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 1:119 MORTON ST APT GB
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10014-3352
Mailing Address - Country:US
Mailing Address - Phone:212-924-7621
Mailing Address - Fax:
Practice Address - Street 1:85 5TH AVE
Practice Address - Street 2:SUITE 901
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-3019
Practice Address - Country:US
Practice Address - Phone:212-741-3448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006997103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV28861Medicare ID - Type Unspecified
NYR52389Medicare UPIN