Provider Demographics
NPI:1699708677
Name:RUFFOLO, JESSICA SOMERVILLE (PHD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:SOMERVILLE
Last Name:RUFFOLO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 CENTERVILLE RD
Mailing Address - Street 2:UNIT 2
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-4381
Mailing Address - Country:US
Mailing Address - Phone:401-529-9921
Mailing Address - Fax:401-615-7544
Practice Address - Street 1:875 CENTERVILLE RD
Practice Address - Street 2:UNIT 2
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-4381
Practice Address - Country:US
Practice Address - Phone:401-529-9921
Practice Address - Fax:401-615-7544
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS0000896103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI29875-9OtherBCBS RI
RI412854OtherBLUECHIP
RI412854OtherBLUECHIP
RI709004399Medicare ID - Type UnspecifiedGROUP NUMBER