Provider Demographics
NPI:1235773086
Name:JESSICA KOBLENZ, PSYD, PLLC
Entity Type:Organization
Organization Name:JESSICA KOBLENZ, PSYD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST III
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOBLENZ
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:516-725-5551
Mailing Address - Street 1:3801 23RD AVE STE 306
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-1978
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3801 23RD AVE STE 306
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11105-1978
Practice Address - Country:US
Practice Address - Phone:516-725-5551
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-05
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty