Provider Demographics
NPI:1912260670
Name:POURAKIS, JENNY G (LCSW)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:G
Last Name:POURAKIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 SARGENT RD
Mailing Address - Street 2:
Mailing Address - City:RIVERVALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07675-6540
Mailing Address - Country:US
Mailing Address - Phone:201-421-7371
Mailing Address - Fax:
Practice Address - Street 1:192 3RD AVE
Practice Address - Street 2:SUITE 12
Practice Address - City:WESTWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07675-2154
Practice Address - Country:US
Practice Address - Phone:201-421-7371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC052386001041C0700X
NY071679-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical