Provider Demographics
NPI:1427253848
Name:LIVINGSTONE, JACK (PHD IN PSYCHOLOGY)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:LIVINGSTONE
Suffix:
Gender:M
Credentials:PHD IN PSYCHOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25127 71ST RD
Mailing Address - Street 2:
Mailing Address - City:BELLEROSE
Mailing Address - State:NY
Mailing Address - Zip Code:11426-2725
Mailing Address - Country:US
Mailing Address - Phone:718-347-3147
Mailing Address - Fax:
Practice Address - Street 1:25127 71ST RD
Practice Address - Street 2:
Practice Address - City:BELLEROSE
Practice Address - State:NY
Practice Address - Zip Code:11426-2725
Practice Address - Country:US
Practice Address - Phone:718-347-3147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY8611103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00941915Medicaid