Healthcare Provider Details

I. General information

NPI: 1619392560
Provider Name (Legal Business Name): JESSICA KOBLENZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2014
Last Update Date: 03/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2540 SHORE BLVD 4I
ASTORIA NY
11102-3941
US

IV. Provider business mailing address

2540 SHORE BLVD 4I
ASTORIA NY
11102-3941
US

V. Phone/Fax

Practice location:
  • Phone: 847-404-0772
  • Fax:
Mailing address:
  • Phone: 847-404-0772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number019849
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: