Healthcare Provider Details

I. General information

NPI: 1295538627
Provider Name (Legal Business Name): JESSICA R GAYVORONSKIY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2025
Last Update Date: 03/31/2025
Certification Date: 03/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 5TH AVE
NEW YORK NY
10118-0110
US

IV. Provider business mailing address

40 E MACON AVE
STATEN ISLAND NY
10308-1315
US

V. Phone/Fax

Practice location:
  • Phone: 516-308-4966
  • Fax:
Mailing address:
  • Phone: 929-238-2460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: