Provider Demographics
NPI:1952738544
Name:ANDERSEN, JENNIFER (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:ANDERSEN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1081 SHORE PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11228-3919
Mailing Address - Country:US
Mailing Address - Phone:347-651-1228
Mailing Address - Fax:
Practice Address - Street 1:117 DOBBIN ST STE 305D
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11222-2803
Practice Address - Country:US
Practice Address - Phone:347-651-1228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-27
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021334-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1285628552OtherAGENCY