Provider Demographics
NPI:1679803969
Name:BLATT, JACQUELINE (LCSW)
Entity type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:
Last Name:BLATT
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 1:8 CENTRAL DR
Mailing Address - Street 2:
Mailing Address - City:GLEN HEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11545-1107
Mailing Address - Country:US
Mailing Address - Phone:516-674-2141
Mailing Address - Fax:516-674-3848
Practice Address - Street 1:47 HUMPHREY DR
Practice Address - Street 2:
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-4022
Practice Address - Country:US
Practice Address - Phone:516-921-7171
Practice Address - Fax:516-496-4958
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-08
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRO3270411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical