Provider Demographics
NPI:1942564950
Name:RUSSOTTO, JESSICA E
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:E
Last Name:RUSSOTTO
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:JESSICA
Other - Middle Name:E
Other - Last Name:SAMUELS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:538 BROADHOLLOW RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-3676
Mailing Address - Country:US
Mailing Address - Phone:631-385-7780
Mailing Address - Fax:
Practice Address - Street 1:538 BROADHOLLOW RD
Practice Address - Street 2:SUITE 202
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-3676
Practice Address - Country:US
Practice Address - Phone:631-385-7780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-25
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist