Provider Demographics
NPI:1609297803
Name:D'ANGELO, JESSICA ALICE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ALICE
Last Name:D'ANGELO
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 1:3474 113TH ST
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368-1455
Mailing Address - Country:US
Mailing Address - Phone:718-429-5700
Mailing Address - Fax:
Practice Address - Street 1:3474 113TH ST
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-1455
Practice Address - Country:US
Practice Address - Phone:718-429-5700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-16
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist