Provider Demographics
NPI:1326326224
Name:LICAUSI, JESSICA (OD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:LICAUSI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:FULMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:25 CRANBERRY ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2762
Mailing Address - Country:US
Mailing Address - Phone:631-740-9384
Mailing Address - Fax:
Practice Address - Street 1:25 CRANBERRY ST STE A
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2762
Practice Address - Country:US
Practice Address - Phone:631-740-9384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-26
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007703-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist