Provider Demographics
NPI:1538185152
Name:TILSON, JAY F (PSYD)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:F
Last Name:TILSON
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 1:109 PROSPECT PARK W
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-3711
Mailing Address - Country:US
Mailing Address - Phone:718-499-5791
Mailing Address - Fax:718-499-5791
Practice Address - Street 1:109 PROSPECT PARK W
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-3711
Practice Address - Country:US
Practice Address - Phone:718-499-5791
Practice Address - Fax:718-499-5791
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010145103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
V65971Medicare ID - Type Unspecified