Provider Demographics
NPI:1306007562
Name:AQUINO, JESSICA (LCSW-R)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:AQUINO
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 COUNTRY WOODS DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JAMES
Mailing Address - State:NY
Mailing Address - Zip Code:11780-2540
Mailing Address - Country:US
Mailing Address - Phone:631-265-2070
Mailing Address - Fax:
Practice Address - Street 1:1444 5TH AVE
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-4147
Practice Address - Country:US
Practice Address - Phone:631-650-2175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-20
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0762421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400008337Medicare PIN