Provider Demographics
NPI:1386266294
Name:AMBALO, JESSICA SARAH
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:SARAH
Last Name:AMBALO
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 1:11 WILLIAM PENN RD
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11023-1043
Mailing Address - Country:US
Mailing Address - Phone:347-971-8184
Mailing Address - Fax:
Practice Address - Street 1:2447 EASTCHESTER RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469-5915
Practice Address - Country:US
Practice Address - Phone:347-971-8184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-13
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist