Provider Demographics
NPI:1619673787
Name:LICATA, JESSICA (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:LICATA
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 VEE JAY DR
Mailing Address - Street 2:
Mailing Address - City:SHOREHAM
Mailing Address - State:NY
Mailing Address - Zip Code:11786-2249
Mailing Address - Country:US
Mailing Address - Phone:631-379-2270
Mailing Address - Fax:
Practice Address - Street 1:1225 MIDDLE COUNTRY RD
Practice Address - Street 2:
Practice Address - City:MIDDLE ISLAND
Practice Address - State:NY
Practice Address - Zip Code:11953-2515
Practice Address - Country:US
Practice Address - Phone:631-637-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-01
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010928225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist