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General NPI Number Information
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NPI Number | 1659884377
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Entity Type | Individual
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Provider Name | JESSICA LATACK PHD
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Gender | Female
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Dates
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Enumeration Date | 11/16/2017
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Last Update Date | 08/19/2019
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Provider Practice Location Address
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Address Line | 200 W 57TH ST STE 507
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City | NEW YORK
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State | NY
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Zip | 10019-3211
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Country | US
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Telephone | 917-817-2422
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Fax |
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Provider Business Mailing Address
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Address Line | 115 W 86TH ST
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City | NEW YORK
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State | NY
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Zip | 10024-3410
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 022815
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License Number State | NY
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