Provider Demographics
NPI:1285070094
Name:JESSICA WAHL
Entity type:Organization
Organization Name:JESSICA WAHL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPECIAL EDUCATION TEACHER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:WAHL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-359-6137
Mailing Address - Street 1:54 HOWARD PL
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-1330
Mailing Address - Country:US
Mailing Address - Phone:516-359-6137
Mailing Address - Fax:
Practice Address - Street 1:54 HOWARD PL
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:NY
Practice Address - Zip Code:11572-1330
Practice Address - Country:US
Practice Address - Phone:516-359-6137
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-20
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2365999252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency