Provider Demographics
NPI:1285124008
Name:VICENTE, JACQUELINE MARIE (LMSW)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:MARIE
Last Name:VICENTE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:MS
Other - First Name:JACQUELINE
Other - Middle Name:MARIE
Other - Last Name:OREGEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2041 47TH ST FL 1
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-1201
Mailing Address - Country:US
Mailing Address - Phone:707-515-9205
Mailing Address - Fax:
Practice Address - Street 1:2041 47TH ST FL 1
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11105-1201
Practice Address - Country:US
Practice Address - Phone:707-515-9205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-17
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103353-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker