Provider Demographics
NPI:1063644292
Name:OVERTON, JESSICA J (RDH)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:J
Last Name:OVERTON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:J
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RCH
Mailing Address - Street 1:61 DELANO ST
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:NY
Mailing Address - Zip Code:13142-1400
Mailing Address - Country:US
Mailing Address - Phone:315-298-6815
Mailing Address - Fax:315-298-7488
Practice Address - Street 1:61 DELANO ST
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:NY
Practice Address - Zip Code:13142-1400
Practice Address - Country:US
Practice Address - Phone:315-298-6815
Practice Address - Fax:315-298-7488
Is Sole Proprietor?:No
Enumeration Date:2009-08-21
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023797124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00023797Medicaid