Provider Demographics
NPI:1215517644
Name:MOSES, JESSICA A
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:A
Last Name:MOSES
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 1:1565 THIERIOT AVE APT 2J
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10460-3418
Mailing Address - Country:US
Mailing Address - Phone:917-605-5225
Mailing Address - Fax:
Practice Address - Street 1:1565 THIERIOT AVE APT 2J
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10460-3418
Practice Address - Country:US
Practice Address - Phone:917-605-5225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-09
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1021094161252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency