Healthcare Provider Details

I. General information

NPI: 1376400010
Provider Name (Legal Business Name): JAMIE YVONNE KITANOF CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2026
Last Update Date: 01/06/2026
Certification Date: 01/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

564 JACKSON AVE
BRONX NY
10455-3104
US

IV. Provider business mailing address

24 BOULEVARD DR
HICKSVILLE NY
11801-4838
US

V. Phone/Fax

Practice location:
  • Phone: 718-292-2683
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number14509527
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: