1144151366 NPI number — MR. JASPER VICTOR OTVERTCHENKO LMSW

Table of content: MR. JASPER VICTOR OTVERTCHENKO LMSW (NPI 1144151366)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144151366 NPI number — MR. JASPER VICTOR OTVERTCHENKO LMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OTVERTCHENKO
Provider First Name:
JASPER
Provider Middle Name:
VICTOR
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LMSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144151366
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/27/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7 PINE WOODS ROAD
Provider Second Line Business Mailing Address:
SUITE 7
Provider Business Mailing Address City Name:
HYDE PARK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12538
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-233-5935
Provider Business Mailing Address Fax Number:
845-233-4726

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7 PINE WOODS ROAD
Provider Second Line Business Practice Location Address:
SUITE 7
Provider Business Practice Location Address City Name:
HYDE PARK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12538
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-233-5935
Provider Business Practice Location Address Fax Number:
845-233-4726
Provider Enumeration Date:
05/27/2026

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: 104100000X , with the licence number:  130929 , 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)





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