Provider Demographics
NPI:1639647837
Name:THALHAMER, JESSICA GRACE (DC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:GRACE
Last Name:THALHAMER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-0188
Mailing Address - Country:US
Mailing Address - Phone:631-417-6505
Mailing Address - Fax:
Practice Address - Street 1:480 UNION BLVD UNIT 188
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-6008
Practice Address - Country:US
Practice Address - Phone:631-417-6505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-06
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013113111N00000X
NY0971161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No111N00000XChiropractic ProvidersChiropractor