Provider Demographics
NPI:1538731369
Name:MANDATO TRUCIOS, JENNIFER LYNNE (CASAC-T, CRPA-P)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNNE
Last Name:MANDATO TRUCIOS
Suffix:
Gender:F
Credentials:CASAC-T, CRPA-P
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:LYNNE
Other - Last Name:MANDATO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:CAMELOT, 460 BRIELLE AVENUE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314
Mailing Address - Country:US
Mailing Address - Phone:718-816-6589
Mailing Address - Fax:
Practice Address - Street 1:CAMELOT, 460 BRIELLE AVENUE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10309
Practice Address - Country:US
Practice Address - Phone:134-792-3137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-12
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY37240101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)