Healthcare Provider Details

I. General information

NPI: 1144063066
Provider Name (Legal Business Name): JESSICA CUSATIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2024
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 E OAK ST
WEST HAZLETON PA
18202-3963
US

IV. Provider business mailing address

212 E OAK ST
WEST HAZLETON PA
18202-3963
US

V. Phone/Fax

Practice location:
  • Phone: 570-790-9184
  • Fax:
Mailing address:
  • Phone: 570-790-9184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSL018820
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: