MEDICARE: MRS. JESSICA GIL IV

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	23386	NY

General Provider Information

NPI Number	:	1790013225
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JESSICA GIL IV

Provider Business Mailing Address
First Line	:	8216 34TH AVE
Second Line	:	SUITE 1B
City	:	JACKSON HEIGHTS
State	:	NY
Zip	:	11372-3051
Country	:	US
Telephone Number	:	347-678-2071
Fax Number	:

Provider Business Practice Location Address
First Line	:	8216 34TH AVE
Second Line	:
City	:	JACKSON HEIGHTS
State	:	NY
Zip	:	11372-3051
Country	:	US
Telephone Number	:	347-678-2071
Fax Number	:

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

Provider Enumeration Date	:	11/20/2009
Last Update Date	:	11/20/2009

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