Provider Demographics
NPI:1063107704
Name:JAY, ELLEN THERESA
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:THERESA
Last Name:JAY
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 1:157 FOX HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11797-1606
Mailing Address - Country:US
Mailing Address - Phone:516-707-8677
Mailing Address - Fax:
Practice Address - Street 1:157 FOX HOLLOW RD
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NY
Practice Address - Zip Code:11797-1606
Practice Address - Country:US
Practice Address - Phone:516-707-8677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty