Provider Demographics
NPI:1679312839
Name:RIVERA, JESSICA ELIZA (MHC)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:ELIZA
Last Name:RIVERA
Suffix:
Gender:F
Credentials:MHC
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:ELIZA
Other - Last Name:SUREN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MHC
Mailing Address - Street 1:57 MARTIN RD N
Mailing Address - Street 2:
Mailing Address - City:BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11714-5119
Mailing Address - Country:US
Mailing Address - Phone:917-940-0897
Mailing Address - Fax:
Practice Address - Street 1:545 SAW MILL RIVER RD STE 3A
Practice Address - Street 2:
Practice Address - City:ARDSLEY
Practice Address - State:NY
Practice Address - Zip Code:10502-2159
Practice Address - Country:US
Practice Address - Phone:917-940-0897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-20
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health