Provider Demographics
NPI:1891210399
Name:MESIDOR, JEAN KESNOLD (PHD)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:KESNOLD
Last Name:MESIDOR
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:16 ATLANTIC AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-3046
Mailing Address - Country:US
Mailing Address - Phone:516-593-1380
Mailing Address - Fax:516-977-7451
Practice Address - Street 1:1454 MADISON AVE W
Practice Address - Street 2:
Practice Address - City:IMMOKALEE
Practice Address - State:FL
Practice Address - Zip Code:34142-2200
Practice Address - Country:US
Practice Address - Phone:239-658-3000
Practice Address - Fax:239-658-3199
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FL103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty