Provider Demographics
NPI:1952406282
Name:SULLIVAN, JACQUELYN RUTH (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JACQUELYN
Middle Name:RUTH
Last Name:SULLIVAN
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:PO BOX 1046
Mailing Address - Street 2:ATTN: SALLY FOLLETT-BILLING SERVICES
Mailing Address - City:NORWICH
Mailing Address - State:NY
Mailing Address - Zip Code:13815
Mailing Address - Country:US
Mailing Address - Phone:607-334-5010
Mailing Address - Fax:607-336-7326
Practice Address - Street 1:76 MAIN STREET
Practice Address - Street 2:SUITE B
Practice Address - City:SIDNEY
Practice Address - State:NY
Practice Address - Zip Code:13838
Practice Address - Country:US
Practice Address - Phone:607-563-4080
Practice Address - Fax:607-336-7326
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2011-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0710141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY713668OtherMVP MOHAWK VALLEY PLAN
NY713668OtherMVP MOHAWK VALLEY PLAN