Provider Demographics
NPI:1124054267
Name:KLEBANOW, JANI L (PHD)
Entity type:Individual
Prefix:DR
First Name:JANI
Middle Name:L
Last Name:KLEBANOW
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:19 WEST 34 STREET
Mailing Address - Street 2:PH SUITE
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-3006
Mailing Address - Country:US
Mailing Address - Phone:917-763-3232
Mailing Address - Fax:212-239-0948
Practice Address - Street 1:19 WEST 34 STREET
Practice Address - Street 2:PH SUITE
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-3006
Practice Address - Country:US
Practice Address - Phone:917-763-3232
Practice Address - Fax:212-239-0948
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011309-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01405114Medicaid
NY01405114Medicaid