Provider Demographics
NPI:1881885440
Name:SOUFFRANT, JEAN VERNET SR (MA NCPSYA)
Entity type:Individual
Prefix:MR
First Name:JEAN
Middle Name:VERNET
Last Name:SOUFFRANT
Suffix:SR
Gender:M
Credentials:MA NCPSYA
Other - Prefix:
Other - First Name:JEAN
Other - Middle Name:V
Other - Last Name:SOUFFRANT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYCHOANALYST
Mailing Address - Street 1:110-17 37TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368
Mailing Address - Country:US
Mailing Address - Phone:718-429-1825
Mailing Address - Fax:718-565-2086
Practice Address - Street 1:110-17 37TH AVENUE
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368
Practice Address - Country:US
Practice Address - Phone:718-429-1825
Practice Address - Fax:718-565-2086
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003761101YM0800X
NY0001361102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health