MEDICARE: DR. JESSICA SOFRANKO KISENWETHER PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	022147-1	NY

General Provider Information

NPI Number	:	1003165044
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JESSICA SOFRANKO KISENWETHER PHD

Provider Business Mailing Address
First Line	:	11 WAYLAND ST
Second Line	:	UNIT 7
City	:	DELMAR
State	:	NY
Zip	:	12054-8218
Country	:	US
Telephone Number	:	518-337-4777
Fax Number	:	518-337-2313

Provider Business Practice Location Address
First Line	:	432 WESTERN AVE
Second Line	:
City	:	ALBANY
State	:	NY
Zip	:	12203-1400
Country	:	US
Telephone Number	:	518-337-4777
Fax Number	:	518-337-2313

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/06/2012
Last Update Date	:	12/01/2014

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