Provider Demographics
NPI:1467114306
Name:ROUGH, JESSICA ELIZABETH
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ELIZABETH
Last Name:ROUGH
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 1:30 RAMLAND RD S STE 200A
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:NY
Mailing Address - Zip Code:10962-2626
Mailing Address - Country:US
Mailing Address - Phone:845-359-0010
Mailing Address - Fax:845-359-3414
Practice Address - Street 1:30 RAMLAND RD S STE 200A
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:NY
Practice Address - Zip Code:10962-2626
Practice Address - Country:US
Practice Address - Phone:845-359-0010
Practice Address - Fax:845-359-3414
Is Sole Proprietor?:No
Enumeration Date:2021-10-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF3477572080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics