Provider Demographics
NPI:1639659170
Name:RUSSO, JENNY MARIE (NP)
Entity Type:Individual
Prefix:MRS
First Name:JENNY
Middle Name:MARIE
Last Name:RUSSO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JENNY
Other - Middle Name:MARIE
Other - Last Name:SERVEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:9407 156TH AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:HOWARD BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11414-2826
Mailing Address - Country:US
Mailing Address - Phone:718-323-3773
Mailing Address - Fax:718-323-3777
Practice Address - Street 1:9407 156TH AVE STE 200
Practice Address - Street 2:
Practice Address - City:HOWARD BEACH
Practice Address - State:NY
Practice Address - Zip Code:11414-2826
Practice Address - Country:US
Practice Address - Phone:718-323-3773
Practice Address - Fax:718-323-3777
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY343495363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty