Provider Demographics
NPI:1730498114
Name:MAROLLO, JESSICA L
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:L
Last Name:MAROLLO
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 1:1203 HILTON AVE
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-4149
Mailing Address - Country:US
Mailing Address - Phone:315-368-6414
Mailing Address - Fax:315-368-6444
Practice Address - Street 1:1203 HILTON AVE
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-4149
Practice Address - Country:US
Practice Address - Phone:315-368-6414
Practice Address - Fax:315-368-6444
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-01
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY069542-11041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY069542-1OtherNEW YORK STATE DEPARTMENT OF EDUCATION OFFICE OF PROFESSIONS