Provider Demographics
NPI:1588933808
Name:PRUSSIN, JENNIFER IVY ROTH (LMSW)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:IVY ROTH
Last Name:PRUSSIN
Suffix:
Gender:F
Credentials:LMSW
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Other - Credentials:
Mailing Address - Street 1:131 WARBURTON AVE FL 3
Mailing Address - Street 2:C/O WJCS
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10701-2721
Mailing Address - Country:US
Mailing Address - Phone:914-231-2590
Mailing Address - Fax:914-231-2129
Practice Address - Street 1:487 S BROADWAY STE 220
Practice Address - Street 2:C/O WJCS
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10705-3269
Practice Address - Country:US
Practice Address - Phone:914-423-4433
Practice Address - Fax:914-423-9434
Is Sole Proprietor?:No
Enumeration Date:2011-12-15
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY084368104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker