MEDICARE: JESSICA VANDERBERG

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	104100000X	Social Worker

General Provider Information

NPI Number	:	1649902214
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA VANDERBERG

Provider Business Mailing Address
First Line	:	16 WIRE MILL RD
Second Line	:
City	:	STAMFORD
State	:	CT
Zip	:	06903-4412
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	16 WIRE MILL RD
Second Line	:
City	:	STAMFORD
State	:	CT
Zip	:	06903-4412
Country	:	US
Telephone Number	:	203-921-6653
Fax Number	:

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

Provider Enumeration Date	:	06/30/2022
Last Update Date	:	06/30/2022

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Directions to “ JESSICA VANDERBERG ” Practice Location

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