Provider Demographics
NPI:1619312717
Name:ALAVA, JESSICA L
Entity Type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:L
Last Name:ALAVA
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 1:93 CRANFORD CT
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-2079
Mailing Address - Country:US
Mailing Address - Phone:718-208-3718
Mailing Address - Fax:
Practice Address - Street 1:93 CRANFORD COURT
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306
Practice Address - Country:US
Practice Address - Phone:718-208-3718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-02
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY557029055174400000X, 174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY557029055OtherMYSELF