Provider Demographics
NPI:1629797907
Name:NIEWALD, JESSICA LYNN
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:NIEWALD
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 1:1110 2ND AVE RM 302
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-2021
Mailing Address - Country:US
Mailing Address - Phone:212-842-0080
Mailing Address - Fax:917-591-8494
Practice Address - Street 1:1110 2ND AVE RM 302
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-2021
Practice Address - Country:US
Practice Address - Phone:212-842-0080
Practice Address - Fax:917-591-8494
Is Sole Proprietor?:No
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026732225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist