Provider Demographics
NPI:1508023516
Name:LEVINE, JESSE BERNARD (PHD)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:BERNARD
Last Name:LEVINE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 BERNARD ST
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050-2902
Mailing Address - Country:US
Mailing Address - Phone:516-767-2464
Mailing Address - Fax:516-944-6452
Practice Address - Street 1:6 BERNARD ST
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:NY
Practice Address - Zip Code:11050-2902
Practice Address - Country:US
Practice Address - Phone:516-767-2464
Practice Address - Fax:516-944-6452
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-19
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005386103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical