Provider Demographics
NPI:1912261488
Name:DESTEFANO, JODY LEIGH
Entity Type:Individual
Prefix:MRS
First Name:JODY
Middle Name:LEIGH
Last Name:DESTEFANO
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 1:9 LINDELL AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-3121
Mailing Address - Country:US
Mailing Address - Phone:631-285-1086
Mailing Address - Fax:
Practice Address - Street 1:9 LINDELL AVE
Practice Address - Street 2:
Practice Address - City:LAKE GROVE
Practice Address - State:NY
Practice Address - Zip Code:11755-3121
Practice Address - Country:US
Practice Address - Phone:631-285-1086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-29
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist