Provider Demographics
NPI:1760290761
Name:SANTISTEBAN, JACKELYN
Entity type:Individual
Prefix:
First Name:JACKELYN
Middle Name:
Last Name:SANTISTEBAN
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 1:444 E BOSTON POST RD STE 206
Mailing Address - Street 2:
Mailing Address - City:MAMARONECK
Mailing Address - State:NY
Mailing Address - Zip Code:10543-3704
Mailing Address - Country:US
Mailing Address - Phone:914-200-0597
Mailing Address - Fax:
Practice Address - Street 1:444 E BOSTON POST RD STE 206
Practice Address - Street 2:
Practice Address - City:MAMARONECK
Practice Address - State:NY
Practice Address - Zip Code:10543-3704
Practice Address - Country:US
Practice Address - Phone:914-200-0597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-21
Last Update Date:2024-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health