Provider Demographics
NPI:1952910838
Name:DORN, JACQUELINE M (LCSW)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:M
Last Name:DORN
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 1:38 EAST RD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180-6861
Mailing Address - Country:US
Mailing Address - Phone:518-330-5590
Mailing Address - Fax:
Practice Address - Street 1:27 2ND ST # B
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-4078
Practice Address - Country:US
Practice Address - Phone:518-330-5590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-28
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY102920104100000X
NY090855011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker