Provider Demographics
NPI:1780920009
Name:MORDI, JESSICA (NP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MORDI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25715 148TH DR
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422-3018
Mailing Address - Country:US
Mailing Address - Phone:347-869-3595
Mailing Address - Fax:
Practice Address - Street 1:25715 148TH DR
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:NY
Practice Address - Zip Code:11422-3018
Practice Address - Country:US
Practice Address - Phone:347-869-3595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-13
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY626663163W00000X
NYF421255-1363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No163W00000XNursing Service ProvidersRegistered Nurse