Provider Demographics
NPI:1396232567
Name:KALISH, JESSICA (LAC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:KALISH
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 BRANCH AVE
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-5323
Mailing Address - Country:US
Mailing Address - Phone:516-312-2710
Mailing Address - Fax:
Practice Address - Street 1:1 IRELAND PL FL 2
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-2955
Practice Address - Country:US
Practice Address - Phone:516-654-4655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-13
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006248171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist