Provider Demographics
NPI:1255113783
Name:JARVIS, JONIQUE
Entity type:Individual
Prefix:
First Name:JONIQUE
Middle Name:
Last Name:JARVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1137 MAGGIE RD
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12550-7031
Mailing Address - Country:US
Mailing Address - Phone:914-806-4473
Mailing Address - Fax:
Practice Address - Street 1:400 E FORDHAM RD FL 6
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-5039
Practice Address - Country:US
Practice Address - Phone:914-806-4473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-18
Last Update Date:2023-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY118734-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker