Provider Demographics
NPI:1164989505
Name:DETOR, JESSICA (LMSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:DETOR
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:CAMP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:4900 BROAD RD
Mailing Address - Street 2:POB NORTH 3N
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13215-2265
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4900 BROAD RD
Practice Address - Street 2:PHYSICIAN OFFICE BUILDING NORTH 3N
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13215-2265
Practice Address - Country:US
Practice Address - Phone:315-949-1031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0688271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical