Provider Demographics
NPI:1356665129
Name:SECRETI, JESSICA KORI
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:KORI
Last Name:SECRETI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1209 OAK ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-1025
Mailing Address - Country:US
Mailing Address - Phone:315-935-5898
Mailing Address - Fax:
Practice Address - Street 1:1209 OAK ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-1025
Practice Address - Country:US
Practice Address - Phone:315-935-5898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-22
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374U00000X, 390200000X
NY376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No374U00000XNursing Service Related ProvidersHome Health Aide
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program