Provider Demographics
NPI:1801634399
Name:BRUTUS, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BRUTUS
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 1:18 MARSHALL LN
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-2814
Mailing Address - Country:US
Mailing Address - Phone:631-377-1468
Mailing Address - Fax:
Practice Address - Street 1:100 PORT WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576-1353
Practice Address - Country:US
Practice Address - Phone:516-562-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-18
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY311709363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health