Healthcare Provider Details

I. General information

NPI: 1215004445
Provider Name (Legal Business Name): JESSICA VICTORIA FORTUNATO PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 10/09/2025
Certification Date: 10/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

154 WATERMAN ST
PROVIDENCE RI
02906
US

IV. Provider business mailing address

154 WATERMAN ST
PROVIDENCE RI
02906-3116
US

V. Phone/Fax

Practice location:
  • Phone: 401-273-3322
  • Fax: 401-270-5700
Mailing address:
  • Phone: 401-273-3322
  • Fax: 401-270-5700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS00986
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: