Provider Demographics
NPI:1871971176
Name:ROEDER, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:ROEDER
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:PO BOX 8
Mailing Address - Street 2:7513 COURT STREET
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:12932-0008
Mailing Address - Country:US
Mailing Address - Phone:518-873-3670
Mailing Address - Fax:518-873-3777
Practice Address - Street 1:7513 COURT STREET
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:NY
Practice Address - Zip Code:12932-0008
Practice Address - Country:US
Practice Address - Phone:518-873-3670
Practice Address - Fax:518-873-3777
Is Sole Proprietor?:No
Enumeration Date:2015-05-07
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY083744-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical