Provider Demographics
NPI:1790111359
Name:THOMASSEN, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:THOMASSEN
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 1:3600 NY-112
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727
Mailing Address - Country:US
Mailing Address - Phone:631-920-8630
Mailing Address - Fax:
Practice Address - Street 1:3600 ROUTE 112
Practice Address - Street 2:
Practice Address - City:CORAM
Practice Address - State:NY
Practice Address - Zip Code:11727-4116
Practice Address - Country:US
Practice Address - Phone:631-338-8171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-16
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
091748-011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker