Provider Demographics
NPI:1629511092
Name:KRIVAC, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:KRIVAC
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 1:1186 BRUCE ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN SQUARE
Mailing Address - State:NY
Mailing Address - Zip Code:11010-1306
Mailing Address - Country:US
Mailing Address - Phone:917-930-4429
Mailing Address - Fax:
Practice Address - Street 1:1-50 51ST AVENUE
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101
Practice Address - Country:US
Practice Address - Phone:718-609-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-02
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3514853235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist