Provider Demographics
NPI:1982178554
Name:COLUCCIO, JENNA NICOLE
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:NICOLE
Last Name:COLUCCIO
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 1:3125 ENOS ST
Mailing Address - Street 2:
Mailing Address - City:BELLMORE
Mailing Address - State:NY
Mailing Address - Zip Code:11710-5318
Mailing Address - Country:US
Mailing Address - Phone:516-512-0044
Mailing Address - Fax:
Practice Address - Street 1:170 WILLIAM ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10038-2612
Practice Address - Country:US
Practice Address - Phone:212-312-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-17
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant