Provider Demographics
NPI:1225786361
Name:ROSEBURG, JESSYKA
Entity Type:Individual
Prefix:
First Name:JESSYKA
Middle Name:
Last Name:ROSEBURG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2937 DAVIS ST # 2
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-2014
Mailing Address - Country:US
Mailing Address - Phone:917-531-7665
Mailing Address - Fax:
Practice Address - Street 1:1325 M ST
Practice Address - Street 2:
Practice Address - City:ELMONT
Practice Address - State:NY
Practice Address - Zip Code:11003-4744
Practice Address - Country:US
Practice Address - Phone:516-519-3372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-17
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty