Provider Demographics
NPI:1730351578
Name:RONDON-JACKSON, RENIE ELIZABETH MARIE (LCSW)
Entity type:Individual
Prefix:
First Name:RENIE
Middle Name:ELIZABETH MARIE
Last Name:RONDON-JACKSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13607 BROOKVILLE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422-1525
Mailing Address - Country:US
Mailing Address - Phone:718-855-7485
Mailing Address - Fax:718-855-1316
Practice Address - Street 1:40 RECTOR ST
Practice Address - Street 2:11TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10006-1705
Practice Address - Country:US
Practice Address - Phone:718-855-7485
Practice Address - Fax:718-855-1316
Is Sole Proprietor?:No
Enumeration Date:2008-04-01
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY057800-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health