Provider Demographics
NPI:1902504475
Name:CIALLELLA, JESSICA LAUREN (LAC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LAUREN
Last Name:CIALLELLA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 ASHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BLAUVELT
Mailing Address - State:NY
Mailing Address - Zip Code:10913-1701
Mailing Address - Country:US
Mailing Address - Phone:845-664-1756
Mailing Address - Fax:
Practice Address - Street 1:259 S MIDDLETOWN RD
Practice Address - Street 2:
Practice Address - City:NANUET
Practice Address - State:NY
Practice Address - Zip Code:10954-3327
Practice Address - Country:US
Practice Address - Phone:845-379-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-23
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007214171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty