Provider Demographics
NPI:1164743761
Name:WAFFLE, JESSICA HOPE (LCSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:HOPE
Last Name:WAFFLE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:262 CONKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13903-2308
Mailing Address - Country:US
Mailing Address - Phone:607-762-6062
Mailing Address - Fax:607-762-8393
Practice Address - Street 1:262 CONKLIN AVE
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13903-2308
Practice Address - Country:US
Practice Address - Phone:607-762-6062
Practice Address - Fax:607-762-8393
Is Sole Proprietor?:No
Enumeration Date:2010-06-17
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0849271041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00583582Medicaid