Provider Demographics
NPI:1346836392
Name:ROTHBERG, JESSICA R
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:R
Last Name:ROTHBERG
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 1:110 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-2507
Mailing Address - Country:US
Mailing Address - Phone:315-349-5511
Mailing Address - Fax:
Practice Address - Street 1:29 E CAYUGA ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-1241
Practice Address - Country:US
Practice Address - Phone:315-326-4100
Practice Address - Fax:315-326-4290
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-14
Last Update Date:2025-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY407134363LP0808X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker