Provider Demographics
NPI:1437954310
Name:RUTA, JESSICA LEIGH
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEIGH
Last Name:RUTA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 MIDLAND ST
Mailing Address - Street 2:
Mailing Address - City:COLD SPRING HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:11724-1808
Mailing Address - Country:US
Mailing Address - Phone:516-404-5288
Mailing Address - Fax:
Practice Address - Street 1:16303 HORACE HARDING EXPY
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365-1454
Practice Address - Country:US
Practice Address - Phone:718-670-2386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-15
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF353695-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily