Provider Demographics
NPI:1003952433
Name:MANCUSO, JENNIFER ANN (OTRL)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:ANN
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2590 LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:EAST MEADOW
Mailing Address - State:NY
Mailing Address - Zip Code:11554-3523
Mailing Address - Country:US
Mailing Address - Phone:516-214-4351
Mailing Address - Fax:
Practice Address - Street 1:168 CHERRY LN
Practice Address - Street 2:
Practice Address - City:CARLE PLACE
Practice Address - State:NY
Practice Address - Zip Code:11514-1741
Practice Address - Country:US
Practice Address - Phone:516-622-6400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011498-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist