Provider Demographics
NPI:1396085304
Name:SULLIVAN, JESSICA C (LCSW-R)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:C
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 STATE ROUTE 17M
Mailing Address - Street 2:SUITE 4
Mailing Address - City:MONROE
Mailing Address - State:NY
Mailing Address - Zip Code:10950-3443
Mailing Address - Country:US
Mailing Address - Phone:845-547-0479
Mailing Address - Fax:845-547-0479
Practice Address - Street 1:360 STATE ROUTE 17M
Practice Address - Street 2:SUITE 4
Practice Address - City:MONROE
Practice Address - State:NY
Practice Address - Zip Code:10950-3443
Practice Address - Country:US
Practice Address - Phone:845-547-0479
Practice Address - Fax:845-547-0479
Is Sole Proprietor?:No
Enumeration Date:2013-02-28
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0855911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical