Provider Demographics
NPI:1568106979
Name:MISTRETTA, JESSICA
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:MISTRETTA
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:BORNEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:179 MIDDLE ISLAND RD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-1517
Mailing Address - Country:US
Mailing Address - Phone:631-880-3081
Mailing Address - Fax:
Practice Address - Street 1:179 MIDDLE ISLAND RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-1517
Practice Address - Country:US
Practice Address - Phone:631-880-3081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-21
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency