Provider Demographics
NPI:1942734090
Name:YEARA, JESSICA NICOLE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:NICOLE
Last Name:YEARA
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 1:760 BROADWAY
Mailing Address - Street 2:ROOM 6A226
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11206-5317
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:760 BROADWAY
Practice Address - Street 2:ROOM 6A226
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206-5317
Practice Address - Country:US
Practice Address - Phone:718-963-5765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-16
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY060176-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program