Provider Demographics
NPI:1245071760
Name:KOEIMAN-RASAVONG, JENNIFER SUZANNE (LMSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SUZANNE
Last Name:KOEIMAN-RASAVONG
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 OAKLEY AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10550-1441
Mailing Address - Country:US
Mailing Address - Phone:914-227-8908
Mailing Address - Fax:
Practice Address - Street 1:685 WHITE PLAINS RD
Practice Address - Street 2:
Practice Address - City:EASTCHESTER
Practice Address - State:NY
Practice Address - Zip Code:10709-5545
Practice Address - Country:US
Practice Address - Phone:646-940-0563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-06
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY091880-011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical