Healthcare Provider Details

I. General information

NPI: 1174315378
Provider Name (Legal Business Name): JASON RIBISI MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2025
Last Update Date: 05/22/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7105 3RD AVE STE 423
BROOKLYN NY
11209-1308
US

IV. Provider business mailing address

1365 N RAILROAD AVE STE 130
STATEN ISLAND NY
10306-2348
US

V. Phone/Fax

Practice location:
  • Phone: 917-312-4804
  • Fax:
Mailing address:
  • Phone: 917-312-4804
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: