Provider Demographics
NPI:1780945436
Name:WONG, JENNIFER MARIE (LCSW-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:WONG
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:MARIE
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:126 E 12TH ST APT 4A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-5320
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:149 E 78TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-0405
Practice Address - Country:US
Practice Address - Phone:212-879-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-30
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY080412-1104100000X
MD227371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker