Provider Demographics
NPI:1417381427
Name:VITALE, JENNA MARIE (MS ED)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:MARIE
Last Name:VITALE
Suffix:
Gender:F
Credentials:MS ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 SHORE RD APT 1E
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-5302
Mailing Address - Country:US
Mailing Address - Phone:516-790-1990
Mailing Address - Fax:
Practice Address - Street 1:420 SHORE RD APT 1E
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561
Practice Address - Country:US
Practice Address - Phone:516-790-1990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-27
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1134654174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist