Provider Demographics
NPI:1740687292
Name:AGOSTINO, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:AGOSTINO
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 1:61 W 74TH ST
Mailing Address - Street 2:APT. 7C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-2433
Mailing Address - Country:US
Mailing Address - Phone:917-842-6622
Mailing Address - Fax:
Practice Address - Street 1:1225 GERARD AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10452-8001
Practice Address - Country:US
Practice Address - Phone:718-960-2959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-28
Last Update Date:2014-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0920231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical