Provider Demographics
NPI:1174058754
Name:DEVITO, JESSICA L
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:DEVITO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:L
Other - Last Name:DEGAMON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11 ELSTON CT
Mailing Address - Street 2:
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-2800
Mailing Address - Country:US
Mailing Address - Phone:631-702-0299
Mailing Address - Fax:
Practice Address - Street 1:11 ELSTON CT
Practice Address - Street 2:
Practice Address - City:LAKE GROVE
Practice Address - State:NY
Practice Address - Zip Code:11755-2800
Practice Address - Country:US
Practice Address - Phone:631-702-0299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-20
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1189762174400000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No174400000XOther Service ProvidersSpecialist