Provider Demographics
NPI:1750740148
Name:REICH, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:REICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:DRYDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1143
Mailing Address - Street 2:3255 MAIN ST #1
Mailing Address - City:MEXICO
Mailing Address - State:NY
Mailing Address - Zip Code:13114
Mailing Address - Country:US
Mailing Address - Phone:619-573-8054
Mailing Address - Fax:
Practice Address - Street 1:3255 MAIN ST
Practice Address - Street 2:#1
Practice Address - City:MEXICO
Practice Address - State:NY
Practice Address - Zip Code:13114
Practice Address - Country:US
Practice Address - Phone:619-573-8054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-15
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY324715164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse