Provider Demographics
NPI:1578299251
Name:CAPUOZZO, JESSICA CAROLINE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:CAROLINE
Last Name:CAPUOZZO
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 1:142 OXFORD PL
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-3017
Mailing Address - Country:US
Mailing Address - Phone:917-952-6626
Mailing Address - Fax:
Practice Address - Street 1:142 OXFORD PL
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-3017
Practice Address - Country:US
Practice Address - Phone:917-952-6626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-26
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY087142101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY087142Medicaid