Provider Demographics
NPI:1275070526
Name:DEMARCO, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DEMARCO
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:PETRUZZI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSED
Mailing Address - Street 1:423 FLINT ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-4037
Mailing Address - Country:US
Mailing Address - Phone:917-359-3901
Mailing Address - Fax:
Practice Address - Street 1:423 FLINT ST
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-4037
Practice Address - Country:US
Practice Address - Phone:917-359-3901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-25
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency