Provider Demographics
NPI:1558064196
Name:BALTAZAR, JESSICA (LMSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BALTAZAR
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3636 33RD ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11106-2329
Mailing Address - Country:US
Mailing Address - Phone:718-426-8110
Mailing Address - Fax:718-426-8116
Practice Address - Street 1:3636 33RD ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11106-2329
Practice Address - Country:US
Practice Address - Phone:718-426-8110
Practice Address - Fax:718-426-8116
Is Sole Proprietor?:No
Enumeration Date:2023-03-23
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10535601104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker