Provider Demographics
NPI:1114454204
Name:GOLDEN, JESSICA A (LMSW)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:A
Last Name:GOLDEN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:A
Other - Last Name:COPENHAVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:1235 MONTAUK HWY
Mailing Address - Street 2:
Mailing Address - City:MASTIC
Mailing Address - State:NY
Mailing Address - Zip Code:11950-2934
Mailing Address - Country:US
Mailing Address - Phone:631-924-3741
Mailing Address - Fax:
Practice Address - Street 1:2799 ROUTE 112 STE 11
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-2535
Practice Address - Country:US
Practice Address - Phone:631-732-5222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-19
Last Update Date:2017-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0830061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical