Provider Demographics
NPI:1639833502
Name:MARTUSCELLO, JENNA JEAN (LMSW)
Entity Type:Individual
Prefix:MS
First Name:JENNA
Middle Name:JEAN
Last Name:MARTUSCELLO
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1375 BUNGALOW LN
Mailing Address - Street 2:
Mailing Address - City:MATTITUCK
Mailing Address - State:NY
Mailing Address - Zip Code:11952-2282
Mailing Address - Country:US
Mailing Address - Phone:631-903-4254
Mailing Address - Fax:
Practice Address - Street 1:7555 MAIN RD
Practice Address - Street 2:
Practice Address - City:MATTITUCK
Practice Address - State:NY
Practice Address - Zip Code:11952-1516
Practice Address - Country:US
Practice Address - Phone:631-298-8642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-27
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY112693104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY112693OtherSOCIAL WORK LICENSE