Provider Demographics
NPI:1174404016
Name:RUDOLPH, JASON MARC (PSYD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:MARC
Last Name:RUDOLPH
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1006
Mailing Address - Street 2:
Mailing Address - City:WAINSCOTT
Mailing Address - State:NY
Mailing Address - Zip Code:11975-1006
Mailing Address - Country:US
Mailing Address - Phone:917-750-8400
Mailing Address - Fax:
Practice Address - Street 1:48 SOUTH BREEZE DRIVE
Practice Address - Street 2:
Practice Address - City:WAINSCOTT
Practice Address - State:NY
Practice Address - Zip Code:11975
Practice Address - Country:US
Practice Address - Phone:917-750-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-09
Last Update Date:2025-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35868103TC0700X
NY017306103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical