Provider Demographics
NPI:1053675553
Name:TORNATORE, JESSICA TARA
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:TARA
Last Name:TORNATORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6018 83RD PL
Mailing Address - Street 2:
Mailing Address - City:MIDDLE VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11379-5477
Mailing Address - Country:US
Mailing Address - Phone:516-965-9905
Mailing Address - Fax:
Practice Address - Street 1:9777 QUEENS BLVD
Practice Address - Street 2:PH
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-3335
Practice Address - Country:US
Practice Address - Phone:718-830-9274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-28
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist