Provider Demographics
NPI:1053897058
Name:BOGETTI, JENNA MICHELLE
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:MICHELLE
Last Name:BOGETTI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 MAYNARD ST
Mailing Address - Street 2:
Mailing Address - City:TUCKAHOE
Mailing Address - State:NY
Mailing Address - Zip Code:10707-3406
Mailing Address - Country:US
Mailing Address - Phone:914-494-4430
Mailing Address - Fax:
Practice Address - Street 1:330 W 58TH ST STE 203
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-1822
Practice Address - Country:US
Practice Address - Phone:212-707-8222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008884-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health