Healthcare Provider Details

I. General information

NPI: 1104051374
Provider Name (Legal Business Name): MRS. JESSICA ELAINE ADELBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2009
Last Update Date: 08/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

998 CROOKED HILL RD BLDG#69
BRENTWOOD NY
11717-1019
US

IV. Provider business mailing address

998 CROOKED HILL RD BLDG#69
BRENTWOOD NY
11717-1019
US

V. Phone/Fax

Practice location:
  • Phone: 631-761-4186
  • Fax: 631-761-4184
Mailing address:
  • Phone: 631-761-4186
  • Fax: 631-761-4184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: