Provider Demographics
NPI:1700135019
Name:MONACO, JESSICA J
Entity type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:J
Last Name:MONACO
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 1:20 CAROL DR
Mailing Address - Street 2:
Mailing Address - City:LAKE RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-2705
Mailing Address - Country:US
Mailing Address - Phone:631-793-3575
Mailing Address - Fax:
Practice Address - Street 1:5225 NESCONSET HWY
Practice Address - Street 2:BLDG 6 SUITE 30
Practice Address - City:PORT JEFF STA
Practice Address - State:NY
Practice Address - Zip Code:11776-2053
Practice Address - Country:US
Practice Address - Phone:631-473-4284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-31
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY864859174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist