Provider Demographics
NPI:1760503775
Name:MERCER, JACQUELYN DIANA (CSWR)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:DIANA
Last Name:MERCER
Suffix:
Gender:F
Credentials:CSWR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 CHERRY ST
Mailing Address - Street 2:APARTMENT 7J
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10002-7932
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:265 CHERRY ST
Practice Address - Street 2:APARTMENT 7J
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-7932
Practice Address - Country:US
Practice Address - Phone:907-362-0145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR039169-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00039169Medicaid
NY00039169Medicaid