Provider Demographics
NPI:1003567025
Name:PANAGIOTIDIS, JESSICA (LMSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:PANAGIOTIDIS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 530
Mailing Address - Street 2:
Mailing Address - City:E NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-0475
Mailing Address - Country:US
Mailing Address - Phone:631-265-9850
Mailing Address - Fax:631-521-9852
Practice Address - Street 1:521 ROUTE 111 STE 202
Practice Address - Street 2:
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788-4358
Practice Address - Country:US
Practice Address - Phone:631-265-9850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-11
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY114681104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker