Healthcare Provider Details

I. General information

NPI: 1114578416
Provider Name (Legal Business Name): JESSICA WOOD PEDIATRIC NURSE PRACTITIONER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2019
Last Update Date: 04/24/2025
Certification Date: 04/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 W ROE BLVD
PATCHOGUE NY
11772-2569
US

IV. Provider business mailing address

14 BOISENBERRY LN
CENTER MORICHES NY
11934-1416
US

V. Phone/Fax

Practice location:
  • Phone: 631-260-1314
  • Fax: 631-629-6762
Mailing address:
  • Phone: 631-275-5545
  • Fax: 631-629-6762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: JESSICA WOOD
Title or Position: NURSE PRACTITIONER
Credential: NP
Phone: 631-275-5545