Provider Demographics
NPI:1851830244
Name:CAVALLO, JENESSA MARIE
Entity Type:Individual
Prefix:
First Name:JENESSA
Middle Name:MARIE
Last Name:CAVALLO
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 1:275 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:NY
Mailing Address - Zip Code:10528-1140
Mailing Address - Country:US
Mailing Address - Phone:914-967-6500
Mailing Address - Fax:914-925-5155
Practice Address - Street 1:275 NORTH ST
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:NY
Practice Address - Zip Code:10528-1140
Practice Address - Country:US
Practice Address - Phone:914-967-6500
Practice Address - Fax:914-925-5155
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-17
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007346101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health