Provider Demographics
NPI:1730342080
Name:BRESSETTE, JACQUELINE M (CRC, CASAC)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:M
Last Name:BRESSETTE
Suffix:
Gender:F
Credentials:CRC, CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 OLD LIVERPOOL RD
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-6238
Mailing Address - Country:US
Mailing Address - Phone:315-453-3911
Mailing Address - Fax:315-453-0197
Practice Address - Street 1:526 OLD LIVERPOOL RD
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-6238
Practice Address - Country:US
Practice Address - Phone:315-453-3911
Practice Address - Fax:315-453-0197
Is Sole Proprietor?:No
Enumeration Date:2008-07-08
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY17727101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01420800Medicaid