MEDICARE: JAQUASIA CRYSTAL VANDROSS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	P120369	NY

General Provider Information

NPI Number	:	1558212399
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAQUASIA CRYSTAL VANDROSS

Provider Business Mailing Address
First Line	:	2277 ANDREWS AVE APT 1D
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10468-5935
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2277 ANDREWS AVE APT 1D
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10468-5935
Country	:	US
Telephone Number	:	929-701-3534
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/06/2026
Last Update Date	:	02/06/2026

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