Provider Demographics
NPI:1902335474
Name:BENJAMIN, JESSICA R (PHD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:R
Last Name:BENJAMIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:243 RIVERSIDE DR APT 1202
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-8647
Mailing Address - Country:US
Mailing Address - Phone:212-874-0490
Mailing Address - Fax:
Practice Address - Street 1:215 W 95TH ST APT 5G
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-6353
Practice Address - Country:US
Practice Address - Phone:212-874-0490
Practice Address - Fax:212-874-0490
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-08
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000704103TP0814X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000704OtherNEW YORK STATE BOARD OF CERTIFICATION