Provider Demographics
NPI:1013295005
Name:EDELSTEIN, JESS (PHD)
Entity Type:Individual
Prefix:DR
First Name:JESS
Middle Name:
Last Name:EDELSTEIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:469 BUCKLAND RD STE 104
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-3737
Mailing Address - Country:US
Mailing Address - Phone:860-670-5207
Mailing Address - Fax:860-432-4540
Practice Address - Street 1:469 BUCKLAND RD STE 104
Practice Address - Street 2:
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-3737
Practice Address - Country:US
Practice Address - Phone:860-670-5207
Practice Address - Fax:860-432-4540
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-26
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool