MEDICARE: JESSYCA MARSHALL LMSW

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	1041C0700X	Clinical Social Worker	0751031	NY

General Provider Information

NPI Number	:	1689993610
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSYCA MARSHALL LMSW

Provider Business Mailing Address
First Line	:	450 HALSEY ST
Second Line	:	#2
City	:	BROOKLYN
State	:	NY
Zip	:	11233
Country	:	US
Telephone Number	:	718-452-9142
Fax Number	:

Provider Business Practice Location Address
First Line	:	450 HALSEY ST
Second Line	:	#2
City	:	BROOKLYN
State	:	NY
Zip	:	11233-1015
Country	:	US
Telephone Number	:	718-452-9142
Fax Number	:

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

Provider Enumeration Date	:	06/01/2010
Last Update Date	:	12/09/2010

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