Provider Demographics
NPI:1497005425
Name:D'AGOSTINO, JESSICA MARIE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:D'AGOSTINO
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 1:16931 GRISSOM DR
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-2698
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:590 FISHERS STATION DR
Practice Address - Street 2:SUITE 130
Practice Address - City:VICTOR
Practice Address - State:NY
Practice Address - Zip Code:14564-9744
Practice Address - Country:US
Practice Address - Phone:585-924-7207
Practice Address - Fax:585-924-7049
Is Sole Proprietor?:No
Enumeration Date:2012-09-18
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022538235Z00000X
IL146012833235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist