Provider Demographics
NPI:1801358817
Name:LIVELY-PAGLIUCA, JENNIFER NYCOLE (LCSW, CADC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:NYCOLE
Last Name:LIVELY-PAGLIUCA
Suffix:
Gender:
Credentials:LCSW, CADC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:NYCOLE
Other - Last Name:FERRIZZI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11480 ENDURING FREEDOM DR.
Mailing Address - Street 2:
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602-5041
Mailing Address - Country:US
Mailing Address - Phone:315-772-4738
Mailing Address - Fax:
Practice Address - Street 1:11050 MOUNT BELVEDRE BLVD
Practice Address - Street 2:RM 1113
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602
Practice Address - Country:US
Practice Address - Phone:315-772-2151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-01
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV8013-S104100000X
NVIC-13111041C0700X
NV00758-C101YA0400X
NV9561-C1041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV250002931Medicaid
NV00758-COtherCADC
NV9561-COtherLCSW
NVIC-1311OtherCSW INTERN