Provider Demographics
NPI:1255408738
Name:CUNNINGHAM, JENNIFER (LCSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:CUNNINGHAM
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:PO BOX 3001
Mailing Address - Street 2:998 CROOKED HILL RD BUILDING #5
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-3001
Mailing Address - Country:US
Mailing Address - Phone:631-329-0373
Mailing Address - Fax:631-907-9345
Practice Address - Street 1:287 SPRINGS FIREPLACE RD
Practice Address - Street 2:BOX 3067
Practice Address - City:EAST HAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11937-4823
Practice Address - Country:US
Practice Address - Phone:631-329-0373
Practice Address - Fax:631-907-9345
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0755471104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN461V1Medicare ID - Type UnspecifiedLCSW