Provider Demographics
NPI:1215166608
Name:SKINNER, JERYL DINA (LCSW)
Entity type:Individual
Prefix:
First Name:JERYL
Middle Name:DINA
Last Name:SKINNER
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 1:349 BEACH 57TH ST
Mailing Address - Street 2:APT 6D
Mailing Address - City:ARVERNE
Mailing Address - State:NY
Mailing Address - Zip Code:11692-1646
Mailing Address - Country:US
Mailing Address - Phone:718-318-0467
Mailing Address - Fax:
Practice Address - Street 1:349 BEACH 57TH ST
Practice Address - Street 2:APT 6D
Practice Address - City:ARVERNE
Practice Address - State:NY
Practice Address - Zip Code:11692-1646
Practice Address - Country:US
Practice Address - Phone:718-318-0467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-07
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0702791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical