Provider Demographics
NPI:1285105486
Name:EVANGELISTA, JAM MARCOS (LMHC)
Entity type:Individual
Prefix:MR
First Name:JAM
Middle Name:MARCOS
Last Name:EVANGELISTA
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 GARDEN PL
Mailing Address - Street 2:
Mailing Address - City:HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11550-1128
Mailing Address - Country:US
Mailing Address - Phone:347-225-4148
Mailing Address - Fax:
Practice Address - Street 1:4404 QUEENS BLVD FL 2
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11104-2406
Practice Address - Country:US
Practice Address - Phone:718-706-1663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009201101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health