Provider Demographics
NPI:1104168004
Name:ZETLIN, JACK (MSED, LMHC, CRC)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:
Last Name:ZETLIN
Suffix:
Gender:M
Credentials:MSED, LMHC, CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 W 107TH ST APT 4W
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-3088
Mailing Address - Country:US
Mailing Address - Phone:212-666-1144
Mailing Address - Fax:
Practice Address - Street 1:202 W 107TH ST APT 4W
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-3088
Practice Address - Country:US
Practice Address - Phone:212-666-1144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-19
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001914101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health