Provider Demographics
NPI:1487223863
Name:DAVIS, JESSICA (MA, LMHC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1235 MONTAUK HWY
Mailing Address - Street 2:
Mailing Address - City:MASTIC
Mailing Address - State:NY
Mailing Address - Zip Code:11950-2917
Mailing Address - Country:US
Mailing Address - Phone:631-772-3270
Mailing Address - Fax:631-924-2413
Practice Address - Street 1:81 SAINT MARKS LN
Practice Address - Street 2:
Practice Address - City:ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11751-4116
Practice Address - Country:US
Practice Address - Phone:631-455-1185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-21
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011404-01101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health