Provider Demographics
NPI:1972799955
Name:RUDOLPH, JEFFREY ALAN
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:ALAN
Last Name:RUDOLPH
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:JEFFREY
Other - Middle Name:A
Other - Last Name:RUDOLPH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD, ABPP
Mailing Address - Street 1:952 5TH AVE
Mailing Address - Street 2:SUITE 2D
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10075-1740
Mailing Address - Country:US
Mailing Address - Phone:212-628-8490
Mailing Address - Fax:212-628-8496
Practice Address - Street 1:952 5TH AVE
Practice Address - Street 2:SUITE 2D
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-1740
Practice Address - Country:US
Practice Address - Phone:212-628-8490
Practice Address - Fax:212-628-8496
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-24
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006419251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management