Provider Demographics
NPI:1063047223
Name:CARLUCCI, JESSICA (LCSW)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:CARLUCCI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 DAYS AVE
Mailing Address - Street 2:
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784-1931
Mailing Address - Country:US
Mailing Address - Phone:631-241-8051
Mailing Address - Fax:
Practice Address - Street 1:28 JONES ST STE 200
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-2941
Practice Address - Country:US
Practice Address - Phone:631-241-8051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-09
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY102396104100000X
NY0912211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker