Provider Demographics
NPI:1881212587
Name:FORTUNA, JAZMIN
Entity Type:Individual
Prefix:MISS
First Name:JAZMIN
Middle Name:
Last Name:FORTUNA
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 1:853 RIVERSIDE DR APT 4F
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-6435
Mailing Address - Country:US
Mailing Address - Phone:347-405-1518
Mailing Address - Fax:
Practice Address - Street 1:6714 41ST AVE
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-8128
Practice Address - Country:US
Practice Address - Phone:718-458-4243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-09
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health