Provider Demographics
NPI:1588927958
Name:MAZZILLO, JENNA
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:MAZZILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 JAMAICA AVE
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-3631
Mailing Address - Country:US
Mailing Address - Phone:516-383-0224
Mailing Address - Fax:
Practice Address - Street 1:65 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803-3631
Practice Address - Country:US
Practice Address - Phone:516-383-0224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-20
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist