Healthcare Provider Details

I. General information

NPI: 1699682674
Provider Name (Legal Business Name): JESSICA DAMATOVA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2026
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11021 73RD RD APT 5E
FOREST HILLS NY
11375-6364
US

IV. Provider business mailing address

11021 73RD RD APT 5E
FOREST HILLS NY
11375-6364
US

V. Phone/Fax

Practice location:
  • Phone: 347-626-9899
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: