Provider Demographics
NPI:1851138648
Name:ISLAM, JABER (MSED)
Entity type:Individual
Prefix:
First Name:JABER
Middle Name:
Last Name:ISLAM
Suffix:
Gender:M
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-1315
Mailing Address - Country:US
Mailing Address - Phone:646-644-0269
Mailing Address - Fax:
Practice Address - Street 1:174 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-1315
Practice Address - Country:US
Practice Address - Phone:646-644-0269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-10
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool