Provider Demographics
NPI:1497314728
Name:KISH, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:KISH
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 1:20 DELTA AVE
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:NY
Mailing Address - Zip Code:13076-3116
Mailing Address - Country:US
Mailing Address - Phone:315-706-5667
Mailing Address - Fax:
Practice Address - Street 1:321 W ONONDAGA ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-3262
Practice Address - Country:US
Practice Address - Phone:315-478-0610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)