Basic Information
| Provider Information | |||||||||
| NPI: | 1780063297 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NEWSOME | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MFT-P | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2590 FRISBY AVE | ||||||||
| Address2: | FIRST FLOOR | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104613240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182391610 | ||||||||
| FaxNumber: | 8456335765 | ||||||||
| Practice Location | |||||||||
| Address1: | 2590 FRISBY AVE | ||||||||
| Address2: | FIRST FLOOR | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104613240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182391610 | ||||||||
| FaxNumber: | 8456335765 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2015 | ||||||||
| LastUpdateDate: | 10/19/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106H00000X | P02597 | NY | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0023701 | 05 | NJ | MEDICAID |