Provider Demographics
NPI:1811380397
Name:TANNACORE, JESSICA (LMSW, CASAC-T)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:TANNACORE
Suffix:
Gender:F
Credentials:LMSW, CASAC-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:367 N WELLWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-3341
Mailing Address - Country:US
Mailing Address - Phone:631-592-8846
Mailing Address - Fax:
Practice Address - Street 1:950 S OYSTER BAY RD
Practice Address - Street 2:ATTN: FORENSIC ACT TEAM
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-3510
Practice Address - Country:US
Practice Address - Phone:516-822-6111
Practice Address - Fax:516-396-2791
Is Sole Proprietor?:No
Enumeration Date:2015-03-09
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY094437-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker