Provider Demographics
NPI:1508288143
Name:JOACHIM, JESSIE
Entity Type:Individual
Prefix:MRS
First Name:JESSIE
Middle Name:
Last Name:JOACHIM
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 1:13502 227TH ST
Mailing Address - Street 2:
Mailing Address - City:LAURELTON
Mailing Address - State:NY
Mailing Address - Zip Code:11413-2438
Mailing Address - Country:US
Mailing Address - Phone:917-370-8191
Mailing Address - Fax:
Practice Address - Street 1:13502 227TH ST
Practice Address - Street 2:
Practice Address - City:LAURELTON
Practice Address - State:NY
Practice Address - Zip Code:11413-2438
Practice Address - Country:US
Practice Address - Phone:917-370-8191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-16
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY553063041174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist