Healthcare Provider Details

I. General information

NPI: 1619294188
Provider Name (Legal Business Name): JESSIE POVEROMO PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2010
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 N VILLAGE AVE STE 216
ROCKVILLE CENTRE NY
11570-3701
US

IV. Provider business mailing address

PO BOX 1029
WEST BABYLON NY
11704-0029
US

V. Phone/Fax

Practice location:
  • Phone: 516-665-9669
  • Fax:
Mailing address:
  • Phone: 516-665-9669
  • Fax: 516-665-9670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number018490
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number018490
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: