Provider Demographics
NPI:1083931356
Name:LUKOSE, JESSY
Entity Type:Individual
Prefix:
First Name:JESSY
Middle Name:
Last Name:LUKOSE
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 1:148 BYRNE AVE
Mailing Address - Street 2:PH
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-4407
Mailing Address - Country:US
Mailing Address - Phone:718-494-1874
Mailing Address - Fax:
Practice Address - Street 1:2601 OCEAN PKWY
Practice Address - Street 2:SUITE 4N98
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-7745
Practice Address - Country:US
Practice Address - Phone:718-616-3780
Practice Address - Fax:718-616-3797
Is Sole Proprietor?:No
Enumeration Date:2010-04-27
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF340702-1363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology