Provider Demographics
NPI:1083012272
Name:EDELSON, JAMIE ILYSSA (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:JAMIE
Middle Name:ILYSSA
Last Name:EDELSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1895 WALT WHITMAN RD
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-3031
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1895 WALT WHITMAN RD
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-3031
Practice Address - Country:US
Practice Address - Phone:631-577-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-21
Last Update Date:2014-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019296-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist