Provider Demographics
NPI:1245770619
Name:PONCE, JESIKA (MED)
Entity type:Individual
Prefix:
First Name:JESIKA
Middle Name:
Last Name:PONCE
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 CORTLAND PL
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-7348
Mailing Address - Country:US
Mailing Address - Phone:631-278-4599
Mailing Address - Fax:
Practice Address - Street 1:29 PINEWOOD DR
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-5612
Practice Address - Country:US
Practice Address - Phone:631-499-1237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-03
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist