Provider Demographics
NPI:1356905301
Name:JENNINGS, JESTINE DEVARGE (LCSW)
Entity type:Individual
Prefix:
First Name:JESTINE
Middle Name:DEVARGE
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 YATES ST
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-1922
Mailing Address - Country:US
Mailing Address - Phone:631-983-7298
Mailing Address - Fax:
Practice Address - Street 1:384 E 149TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10455-3908
Practice Address - Country:US
Practice Address - Phone:631-983-7298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-25
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0869921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical