Provider Demographics
NPI:1366726101
Name:DEZZUTTI, JESSICA W (MED)
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:W
Last Name:DEZZUTTI
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 GRANT ST
Mailing Address - Street 2:STE. 1
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-4734
Mailing Address - Country:US
Mailing Address - Phone:703-501-6921
Mailing Address - Fax:
Practice Address - Street 1:626 GRANT ST
Practice Address - Street 2:STE. 1
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-4734
Practice Address - Country:US
Practice Address - Phone:703-501-6921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst