Provider Demographics
NPI:1780938316
Name:MENDOZA, JESSICA EVA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:EVA
Last Name:MENDOZA
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 1:2363 GRAND AVE
Mailing Address - Street 2:APT 10C3
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-3102
Mailing Address - Country:US
Mailing Address - Phone:516-717-8275
Mailing Address - Fax:
Practice Address - Street 1:2363 GRAND AVE
Practice Address - Street 2:APT 10C3
Practice Address - City:BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510-3102
Practice Address - Country:US
Practice Address - Phone:516-717-8275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-05
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator