Provider Demographics
NPI:1891466819
Name:NUSBAUM, JESSICA LEE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:LEE
Last Name:NUSBAUM
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7403 COMMONWEALTH BLVD BLDG 57
Mailing Address - Street 2:
Mailing Address - City:BELLEROSE
Mailing Address - State:NY
Mailing Address - Zip Code:11426-1839
Mailing Address - Country:US
Mailing Address - Phone:718-264-4574
Mailing Address - Fax:
Practice Address - Street 1:7403 COMMONWEALTH BLVD BLDG 55
Practice Address - Street 2:
Practice Address - City:BELLEROSE
Practice Address - State:NY
Practice Address - Zip Code:11426-1839
Practice Address - Country:US
Practice Address - Phone:718-264-4574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-21
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022689103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist