Provider Demographics
NPI:1003242009
Name:BENARDELLO, JESSICA S (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:S
Last Name:BENARDELLO
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3107 34TH AVE
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11106-2641
Mailing Address - Country:US
Mailing Address - Phone:773-456-3067
Mailing Address - Fax:
Practice Address - Street 1:3711 35TH AVE
Practice Address - Street 2:SUITE 3C & 3G
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11101-1524
Practice Address - Country:US
Practice Address - Phone:718-706-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-23
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY036629225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist