Provider Demographics
NPI:1396382511
Name:ERMILIO, JESSICA OLSON (PSYD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:OLSON
Last Name:ERMILIO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:FAY
Other - Last Name:OLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:110 LIVINGSTON ST APT 7U
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-5061
Mailing Address - Country:US
Mailing Address - Phone:484-319-9028
Mailing Address - Fax:
Practice Address - Street 1:136 MADISON AVE FL 6
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6795
Practice Address - Country:US
Practice Address - Phone:212-828-7473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-06
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023544-01103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist