Provider Demographics
NPI:1073601761
Name:BACKFIELD-WEISS, JILL (PHD)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:
Last Name:BACKFIELD-WEISS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 EAST 54TH ST.
Mailing Address - Street 2:SUITE 1B, OFFICE 3
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022
Mailing Address - Country:US
Mailing Address - Phone:212-691-6887
Mailing Address - Fax:
Practice Address - Street 1:220 EAST 54TH ST.
Practice Address - Street 2:SUITE 1B, OFFICE 3
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022
Practice Address - Country:US
Practice Address - Phone:212-691-6887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013025103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0-1790261Medicaid
NYV91431Medicare ID - Type Unspecified