Provider Demographics
NPI:1538819636
Name:ELIACIN, JESSICA BONEA (MA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:BONEA
Last Name:ELIACIN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3522 SUNCHASE LN APT 903
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-3192
Mailing Address - Country:US
Mailing Address - Phone:434-250-3916
Mailing Address - Fax:
Practice Address - Street 1:3208 HERSHBERGER RD NW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24017-1842
Practice Address - Country:US
Practice Address - Phone:540-227-8426
Practice Address - Fax:540-563-3084
Is Sole Proprietor?:No
Enumeration Date:2022-03-24
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704011037101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0704011037Medicaid