Healthcare Provider Details

I. General information

NPI: 1871128637
Provider Name (Legal Business Name): JESSICA MARIE VALLES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA MARIE ANTUNOVIC

II. Dates (important events)

Enumeration Date: 03/11/2020
Last Update Date: 08/02/2026
Certification Date: 08/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 VIOLET AVE
POUGHKEEPSIE NY
12601-1034
US

IV. Provider business mailing address

79 E DORSEY LN LOT 22
POUGHKEEPSIE NY
12601-1060
US

V. Phone/Fax

Practice location:
  • Phone: 845-741-1807
  • Fax: 845-471-1815
Mailing address:
  • Phone: 845-921-5226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: