Provider Demographics
NPI:1689933095
Name:FUENTES, JESSICA IVONNE (PA)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:IVONNE
Last Name:FUENTES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8934 221ST ST
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11427-2508
Mailing Address - Country:US
Mailing Address - Phone:914-607-2020
Mailing Address - Fax:
Practice Address - Street 1:2590 FRISBY AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-3240
Practice Address - Country:US
Practice Address - Phone:718-409-9400
Practice Address - Fax:718-409-9440
Is Sole Proprietor?:No
Enumeration Date:2012-05-07
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015588363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant