Provider Demographics
NPI:1720203607
Name:CRESPO, JESSICA (PA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:CRESPO
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 1:1366 VICTORY BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-3907
Mailing Address - Country:US
Mailing Address - Phone:718-442-8351
Mailing Address - Fax:718-442-4073
Practice Address - Street 1:1366 VICTORY BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-3907
Practice Address - Country:US
Practice Address - Phone:718-442-8351
Practice Address - Fax:718-442-4073
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007991-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY007991-1OtherLIN.
NY007991-1OtherLIN.