Provider Demographics
NPI:1336805423
Name:ROYAL, JESSICA DANIELA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:DANIELA
Last Name:ROYAL
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 1:82 REGAN RD
Mailing Address - Street 2:
Mailing Address - City:POTSDAM
Mailing Address - State:NY
Mailing Address - Zip Code:13676-3208
Mailing Address - Country:US
Mailing Address - Phone:920-627-2140
Mailing Address - Fax:
Practice Address - Street 1:22 DEPOT ST STE 19
Practice Address - Street 2:
Practice Address - City:POTSDAM
Practice Address - State:NY
Practice Address - Zip Code:13676-1140
Practice Address - Country:US
Practice Address - Phone:315-325-3890
Practice Address - Fax:207-823-3715
Is Sole Proprietor?:No
Enumeration Date:2021-11-12
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY115698104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker