Provider Demographics
NPI:1205493780
Name:KISSANE, JEDIDIAH LIGUORI
Entity type:Individual
Prefix:
First Name:JEDIDIAH
Middle Name:LIGUORI
Last Name:KISSANE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 DEWITTSHIRE RD S
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13214-2212
Mailing Address - Country:US
Mailing Address - Phone:315-559-9827
Mailing Address - Fax:
Practice Address - Street 1:421 MONTGOMERY ST STE 1000A
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-2982
Practice Address - Country:US
Practice Address - Phone:315-435-3230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-21
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator