Provider Demographics
NPI:1104051374
Name:ADELBERG, JESSICA ELAINE
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:ELAINE
Last Name:ADELBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:998 CROOKED HILL RD
Mailing Address - Street 2:BLDG#69
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-1019
Mailing Address - Country:US
Mailing Address - Phone:631-761-4186
Mailing Address - Fax:631-761-4184
Practice Address - Street 1:998 CROOKED HILL RD
Practice Address - Street 2:BLDG#69
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-1019
Practice Address - Country:US
Practice Address - Phone:631-761-4186
Practice Address - Fax:631-761-4184
Is Sole Proprietor?:No
Enumeration Date:2009-05-18
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01175277Medicaid