Provider Demographics
NPI:1932310208
Name:HARKINS-JAISLE, THERESA EMILY (LCSW)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:EMILY
Last Name:HARKINS-JAISLE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1063 MANOR LN
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-6224
Mailing Address - Country:US
Mailing Address - Phone:631-366-5802
Mailing Address - Fax:631-366-5884
Practice Address - Street 1:1063 MANOR LN
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-6224
Practice Address - Country:US
Practice Address - Phone:631-366-5802
Practice Address - Fax:631-366-5884
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0731041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN62801Medicare ID - Type Unspecified