Provider Demographics
NPI:1598382145
Name:JANICOLA, JESSICA RANDEL (PSYD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:RANDEL
Last Name:JANICOLA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 TRESSER BLVD APT 624
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06901-3438
Mailing Address - Country:US
Mailing Address - Phone:610-574-5136
Mailing Address - Fax:
Practice Address - Street 1:100 TRESSER BLVD APT 624
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06901-3438
Practice Address - Country:US
Practice Address - Phone:610-574-5136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-30
Last Update Date:2025-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
NY024698103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program