Provider Demographics
NPI:1477974384
Name:D'AMICO, JILLIAN
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:D'AMICO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JILLIAN
Other - Middle Name:
Other - Last Name:SARNELLI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:111 GALWAY PL
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-3640
Mailing Address - Country:US
Mailing Address - Phone:201-833-9500
Mailing Address - Fax:201-862-0095
Practice Address - Street 1:3333 HYLAN BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-3608
Practice Address - Country:US
Practice Address - Phone:718-448-3210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-18
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00318500363AS0400X
NY017455363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical