Provider Demographics
NPI:1285786483
Name:SIMON, JACQUELINE LISA (PSYD)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:LISA
Last Name:SIMON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 E 70TH ST
Mailing Address - Street 2:APT. 1FE
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-8625
Mailing Address - Country:US
Mailing Address - Phone:646-242-0686
Mailing Address - Fax:212-838-7158
Practice Address - Street 1:329 E 62ND ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-7705
Practice Address - Country:US
Practice Address - Phone:212-838-4333
Practice Address - Fax:212-838-7158
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015689103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VN1001Medicare UPIN