Provider Demographics
NPI:1174297261
Name:DORNEMANN, JESSICA NICOLE (ATC)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:NICOLE
Last Name:DORNEMANN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:MISS
Other - First Name:JESSICA
Other - Middle Name:NICOLE
Other - Last Name:LOMBARDO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:155 WHITE RD
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-2247
Mailing Address - Country:US
Mailing Address - Phone:203-561-0091
Mailing Address - Fax:
Practice Address - Street 1:1000 HEMPSTEAD AVE
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-1135
Practice Address - Country:US
Practice Address - Phone:516-323-3607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002570-12083S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports Medicine