Provider Demographics
NPI:1215147996
Name:HUMPHREY, JENNIFER (LCSW)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
Last Name:HUMPHREY
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 1:345 W 12TH ST
Mailing Address - Street 2:3
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10014-1702
Mailing Address - Country:US
Mailing Address - Phone:212-255-9093
Mailing Address - Fax:
Practice Address - Street 1:225 WEST 12TH ST.
Practice Address - Street 2:STE 1B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011
Practice Address - Country:US
Practice Address - Phone:212-255-2216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRO40927102L00000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN79831Medicare PIN