Provider Demographics
NPI:1578959029
Name:BASTA, JESSICA (TSHH)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BASTA
Suffix:
Gender:F
Credentials:TSHH
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:GILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:TSHH
Mailing Address - Street 1:534 LEHIGH RD
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:NY
Mailing Address - Zip Code:13142-2414
Mailing Address - Country:US
Mailing Address - Phone:315-408-5866
Mailing Address - Fax:
Practice Address - Street 1:159 W 1ST ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-2045
Practice Address - Country:US
Practice Address - Phone:315-342-9575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-11
Last Update Date:2015-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7360042355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant