Provider Demographics
NPI:1487881736
Name:JANTZEN, SUSAN LESLIE (LCSW)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:LESLIE
Last Name:JANTZEN
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 1:1550 YORK AVE
Mailing Address - Street 2:APT. 16B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-5970
Mailing Address - Country:US
Mailing Address - Phone:212-249-5861
Mailing Address - Fax:
Practice Address - Street 1:98120 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-4357
Practice Address - Country:US
Practice Address - Phone:718-830-0246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-14
Last Update Date:2009-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP047798-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical