Healthcare Provider Details

I. General information

NPI: 1558009548
Provider Name (Legal Business Name): JASMYNE JAEDYN LIEPKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2022
Last Update Date: 05/20/2022
Certification Date: 05/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8074 THURSTON DR
CICERO NY
13039-9062
US

IV. Provider business mailing address

8074 THURSTON DR
CICERO NY
13039-9062
US

V. Phone/Fax

Practice location:
  • Phone: 315-706-4937
  • Fax:
Mailing address:
  • Phone: 131-570-6493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: