Provider Demographics
NPI:1073997284
Name:WAFER, JESSICA LYNN (MSED, PD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:WAFER
Suffix:
Gender:F
Credentials:MSED, PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 CAVALIER CT
Mailing Address - Street 2:
Mailing Address - City:RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:11961-1706
Mailing Address - Country:US
Mailing Address - Phone:631-445-5265
Mailing Address - Fax:
Practice Address - Street 1:25 LITTLE PLAINS RD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-4550
Practice Address - Country:US
Practice Address - Phone:631-266-4411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-17
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool