Healthcare Provider Details

I. General information

NPI: 1184250474
Provider Name (Legal Business Name): JESSICA MAE ORENSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESS ORENSE

II. Dates (important events)

Enumeration Date: 03/18/2020
Last Update Date: 03/18/2020
Certification Date: 03/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

248 W 108TH ST
NEW YORK NY
10025-2956
US

IV. Provider business mailing address

248 W 108TH ST
NEW YORK NY
10025-2956
US

V. Phone/Fax

Practice location:
  • Phone: 212-663-3000
  • Fax:
Mailing address:
  • Phone: 212-663-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberP103172
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: