Provider Demographics
NPI:1346067188
Name:PEREZ, JENESIS NA
Entity type:Individual
Prefix:
First Name:JENESIS
Middle Name:NA
Last Name:PEREZ
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:JENESIS
Other - Middle Name:
Other - Last Name:MATOS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMSW
Mailing Address - Street 1:1 SANFORD AVE
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:10918-1206
Mailing Address - Country:US
Mailing Address - Phone:347-443-4398
Mailing Address - Fax:
Practice Address - Street 1:227 MAIN ST
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:NY
Practice Address - Zip Code:10924-2195
Practice Address - Country:US
Practice Address - Phone:347-443-4398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1229601041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool