Provider Demographics
NPI:1932935574
Name:STANNARD-BACKUS, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:STANNARD-BACKUS
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 1:2841 THOUSAND ACRES RD
Mailing Address - Street 2:
Mailing Address - City:DELANSON
Mailing Address - State:NY
Mailing Address - Zip Code:12053-1917
Mailing Address - Country:US
Mailing Address - Phone:518-875-6141
Mailing Address - Fax:
Practice Address - Street 1:2841 THOUSAND ACRES RD
Practice Address - Street 2:
Practice Address - City:DELANSON
Practice Address - State:NY
Practice Address - Zip Code:12053-1917
Practice Address - Country:US
Practice Address - Phone:518-875-6141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-10
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY125039-01101Y00000X
NY101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health