1285741975 NPI number — JACQUELYN HOUT-ROSS LCSW

Table of content: JACQUELYN HOUT-ROSS LCSW (NPI 1285741975)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285741975 NPI number — JACQUELYN HOUT-ROSS LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOUT-ROSS
Provider First Name:
JACQUELYN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROSS
Provider Other First Name:
JACQUELYN
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1285741975
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2215 BURDETT AVE
Provider Second Line Business Mailing Address:
BEHAVIORAL HEALTH DEPT
Provider Business Mailing Address City Name:
TROY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12180-2466
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-271-3300
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2215 BURDETT AVE
Provider Second Line Business Practice Location Address:
BEHAVIORAL HEALTH DEPT
Provider Business Practice Location Address City Name:
TROY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12180-2466
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-271-3300
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/25/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  070025 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)