1558169623 NPI number — JR NURSE PRACTITIONER IN PSYCHIATRY, PLLC

Table of content: (NPI 1558169623)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558169623 NPI number — JR NURSE PRACTITIONER IN PSYCHIATRY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JR NURSE PRACTITIONER IN PSYCHIATRY, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558169623
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/05/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
99 HYDE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALLSTON SPA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12020-1607
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-368-1691
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
430 FRANKLIN ST STE 2304
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SCHENECTADY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12305-2018
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-788-7983
Provider Business Practice Location Address Fax Number:
866-616-2109
Provider Enumeration Date:
03/05/2025

Additional Information

Authorized Official

Authorized Official Last Name:
EDICK
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
Authorized Official Title or Position:
HEALTHCARE ADMINISTRATOR
Authorized Official Telephone Number:
518-788-7983

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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