Provider Demographics
NPI:1750088829
Name:BACARELLA, JESSICA MARIE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:BACARELLA
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 1:15805 CRYDERS LN
Mailing Address - Street 2:
Mailing Address - City:WHITESTONE
Mailing Address - State:NY
Mailing Address - Zip Code:11357-2704
Mailing Address - Country:US
Mailing Address - Phone:347-804-7118
Mailing Address - Fax:
Practice Address - Street 1:15050 14TH RD
Practice Address - Street 2:
Practice Address - City:WHITESTONE
Practice Address - State:NY
Practice Address - Zip Code:11357-2609
Practice Address - Country:US
Practice Address - Phone:718-767-0071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-09
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY235Z00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist