MEDICARE: JENNIFER MASSARO MSED

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	506611111	NY
2	103K00000X	Behavior Analyst	000213	NY

General Provider Information

NPI Number	:	1902169444
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER MASSARO MSED

Provider Business Mailing Address
First Line	:	10 NEW MILL RD
Second Line	:
City	:	SMITHTOWN
State	:	NY
Zip	:	11787-3324
Country	:	US
Telephone Number	:	631-741-4790
Fax Number	:

Provider Business Practice Location Address
First Line	:	10 NEW MILL RD
Second Line	:
City	:	SMITHTOWN
State	:	NY
Zip	:	11787-3324
Country	:	US
Telephone Number	:	631-741-4790
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/20/2012
Last Update Date	:	10/24/2023

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