Provider Demographics
NPI:1487121497
Name:RUSSO, JACQUELINE (PSYD)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3083 23RD ST APT 2A
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11102-3325
Mailing Address - Country:US
Mailing Address - Phone:516-317-1876
Mailing Address - Fax:
Practice Address - Street 1:351 MANVILLE RD STE 104
Practice Address - Street 2:
Practice Address - City:PLEASANTVILLE
Practice Address - State:NY
Practice Address - Zip Code:10570-2166
Practice Address - Country:US
Practice Address - Phone:413-384-9240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-28
Last Update Date:2018-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022242-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist