Provider Demographics
NPI:1255709903
Name:FOSSNER, JODI
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:FOSSNER
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 1:16 HARDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:TAPPAN
Mailing Address - State:NY
Mailing Address - Zip Code:10983-1109
Mailing Address - Country:US
Mailing Address - Phone:917-459-7122
Mailing Address - Fax:
Practice Address - Street 1:16 HARDWOOD DR
Practice Address - Street 2:
Practice Address - City:TAPPAN
Practice Address - State:NY
Practice Address - Zip Code:10983-1109
Practice Address - Country:US
Practice Address - Phone:917-459-7122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-11
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
NY47-5029569174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist