=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164989505
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA DETOR LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2019
-----------------------------------------------------
Last Update Date | 02/21/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4900 BROAD RD PHYSICIAN OFFICE BUILDING NORTH 3N
-----------------------------------------------------
City | SYRACUSE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13215-2265
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-949-1031
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4900 BROAD RD POB NORTH 3N
-----------------------------------------------------
City | SYRACUSE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13215-2265
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 068827
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------