Provider Demographics
NPI:1083402457
Name:WEINER, JILLIAN NICOLE
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:NICOLE
Last Name:WEINER
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 1:70 GAINSBOROUGH RD
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-2871
Mailing Address - Country:US
Mailing Address - Phone:631-245-9907
Mailing Address - Fax:
Practice Address - Street 1:234 AIRPORT PLAZA BLVD
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-3917
Practice Address - Country:US
Practice Address - Phone:631-767-1589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-28
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY108522104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker