Provider Demographics
NPI:1376777367
Name:TESAK, JENNIFER ANN (PHD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ANN
Last Name:TESAK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:258 GENESEE ST
Mailing Address - Street 2:SUITE 505
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-4636
Mailing Address - Country:US
Mailing Address - Phone:315-732-3431
Mailing Address - Fax:866-822-2343
Practice Address - Street 1:258 GENESEE ST
Practice Address - Street 2:SUITE 505
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-4636
Practice Address - Country:US
Practice Address - Phone:315-732-3431
Practice Address - Fax:866-822-2343
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-06
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP68563103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical