Provider Demographics
NPI:1558169623
Name:JR NURSE PRACTITIONER IN PSYCHIATRY, PLLC
Entity type:Organization
Organization Name:JR NURSE PRACTITIONER IN PSYCHIATRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTHCARE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:EDICK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:518-788-7983
Mailing Address - Street 1:99 HYDE BLVD
Mailing Address - Street 2:
Mailing Address - City:BALLSTON SPA
Mailing Address - State:NY
Mailing Address - Zip Code:12020-1607
Mailing Address - Country:US
Mailing Address - Phone:518-368-1691
Mailing Address - Fax:
Practice Address - Street 1:430 FRANKLIN ST STE 2304
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12305-2018
Practice Address - Country:US
Practice Address - Phone:518-788-7983
Practice Address - Fax:866-616-2109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-05
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty