Provider Demographics
NPI:1609574375
Name:MERCADO, JESSICA M
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:M
Last Name:MERCADO
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 1:31 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:HAVERSTRAW
Mailing Address - State:NY
Mailing Address - Zip Code:10927-1831
Mailing Address - Country:US
Mailing Address - Phone:845-282-3818
Mailing Address - Fax:
Practice Address - Street 1:503 GRASSLANDS RD
Practice Address - Street 2:
Practice Address - City:VALHALLA
Practice Address - State:NY
Practice Address - Zip Code:10595-1503
Practice Address - Country:US
Practice Address - Phone:914-593-0593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-21
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist