Provider Demographics
NPI:1114578416
Name:JESSICA WOOD PEDIATRIC NURSE PRACTITIONER PLLC
Entity Type:Organization
Organization Name:JESSICA WOOD PEDIATRIC NURSE PRACTITIONER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:PNP
Authorized Official - Phone:631-488-0612
Mailing Address - Street 1:14 BOISENBERRY LN
Mailing Address - Street 2:
Mailing Address - City:CENTER MORICHES
Mailing Address - State:NY
Mailing Address - Zip Code:11934-1416
Mailing Address - Country:US
Mailing Address - Phone:631-275-5545
Mailing Address - Fax:631-629-6762
Practice Address - Street 1:363 ROUTE 111 STE 103
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-4750
Practice Address - Country:US
Practice Address - Phone:631-488-0612
Practice Address - Fax:631-629-6762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-27
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty