Provider Demographics
NPI:1932780038
Name:DERITO, JACLYN RITA (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:JACLYN
Middle Name:RITA
Last Name:DERITO
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 ECHODALE AVE # 20
Mailing Address - Street 2:
Mailing Address - City:BALDWINSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13027-1224
Mailing Address - Country:US
Mailing Address - Phone:315-559-7593
Mailing Address - Fax:
Practice Address - Street 1:20 ECHODALE AVE
Practice Address - Street 2:
Practice Address - City:BALDWINSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13027-1224
Practice Address - Country:US
Practice Address - Phone:315-559-7593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY105484104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker