Provider Demographics
NPI:1932352366
Name:RANDAZZO, JESSICA LYNNE (PT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNNE
Last Name:RANDAZZO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:798 BROOKRIDGE DR
Mailing Address - Street 2:APARTMENT 16
Mailing Address - City:VALLEY COTTAGE
Mailing Address - State:NY
Mailing Address - Zip Code:10989-1851
Mailing Address - Country:US
Mailing Address - Phone:845-267-8574
Mailing Address - Fax:
Practice Address - Street 1:798 BROOKRIDGE DR
Practice Address - Street 2:APARTMENT 16
Practice Address - City:VALLEY COTTAGE
Practice Address - State:NY
Practice Address - Zip Code:10989-1851
Practice Address - Country:US
Practice Address - Phone:845-267-8574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-29
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028569225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist