Provider Demographics
NPI:1063089407
Name:BERRY, JESSICA LEIGH (LPN)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEIGH
Last Name:BERRY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3453 STATE ROUTE 12B
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NY
Mailing Address - Zip Code:13323-4627
Mailing Address - Country:US
Mailing Address - Phone:315-399-8890
Mailing Address - Fax:
Practice Address - Street 1:3453 STATE ROUTE 12B
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NY
Practice Address - Zip Code:13323-4627
Practice Address - Country:US
Practice Address - Phone:315-399-8890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-04
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY309904-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse