=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659987790
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA WAKEFIELD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2020
-----------------------------------------------------
Last Update Date | 09/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 FRANKLIN ST STE 102
-----------------------------------------------------
City | SCHENECTADY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12305-2100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-780-9322
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 600 FRANKLIN ST STE 102
-----------------------------------------------------
City | SCHENECTADY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12305-2100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-780-9322
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 175T00000X
-----------------------------------------------------
Taxonomy Name | Peer Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------