Provider Demographics
NPI:1528515624
Name:JACKOWITZ, SHELBY
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:JACKOWITZ
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 1:240 E 27TH ST
Mailing Address - Street 2:APT 7A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-9277
Mailing Address - Country:US
Mailing Address - Phone:862-955-0109
Mailing Address - Fax:
Practice Address - Street 1:260 MADISON AVE
Practice Address - Street 2:STE 8051 AND SET 8065
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-2401
Practice Address - Country:US
Practice Address - Phone:646-661-3840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-06
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY095657104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker