Provider Demographics
NPI:1972321016
Name:JUDGE, JACKLYNN ILENE
Entity type:Individual
Prefix:
First Name:JACKLYNN
Middle Name:ILENE
Last Name:JUDGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1214 E 73RD ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-3676
Mailing Address - Country:US
Mailing Address - Phone:646-617-3811
Mailing Address - Fax:
Practice Address - Street 1:3858 NOSTRAND AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-2050
Practice Address - Country:US
Practice Address - Phone:718-698-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-27
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1-24-75165103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst