Healthcare Provider Details

I. General information

NPI: 1417595257
Provider Name (Legal Business Name): JENNA DITOMMASO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2019
Last Update Date: 12/21/2020
Certification Date: 12/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 JONES CT
MASSAPEQUA PARK NY
11762-3235
US

IV. Provider business mailing address

4 JONES CT
MASSAPEQUA PARK NY
11762-3235
US

V. Phone/Fax

Practice location:
  • Phone: 516-633-5393
  • Fax:
Mailing address:
  • Phone: 516-633-5393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: