Provider Demographics
NPI:1710076096
Name:CASEY, JESSICA L
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:CASEY
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 1:1301 TRUMANSBURG RD
Mailing Address - Street 2:SUITE H
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1397
Mailing Address - Country:US
Mailing Address - Phone:607-272-6880
Mailing Address - Fax:607-272-1436
Practice Address - Street 1:1301 TRUMANSBURG RD
Practice Address - Street 2:SUITE H
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1397
Practice Address - Country:US
Practice Address - Phone:607-272-6880
Practice Address - Fax:607-272-1436
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY221223208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02272517Medicaid