Provider Demographics
NPI:1982441358
Name:BAUTISTA, JEANNETTE
Entity type:Individual
Prefix:
First Name:JEANNETTE
Middle Name:
Last Name:BAUTISTA
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 1:4609 69TH ST APT 421
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-5964
Mailing Address - Country:US
Mailing Address - Phone:718-608-4922
Mailing Address - Fax:
Practice Address - Street 1:225 BROADWAY STE 2060
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10007-3748
Practice Address - Country:US
Practice Address - Phone:646-389-9778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-11
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health