Provider Demographics
NPI:1134532799
Name:KOENIG, JESSICA MARIE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:KOENIG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:MARIE
Other - Last Name:HUGHES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:52 HARDING ST
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-1111
Mailing Address - Country:US
Mailing Address - Phone:917-603-7871
Mailing Address - Fax:
Practice Address - Street 1:52 HARDING ST
Practice Address - Street 2:
Practice Address - City:EAST NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11731-1111
Practice Address - Country:US
Practice Address - Phone:917-603-7871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY163424246XS1301X, 2471S1302X, 2471V0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471V0105XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistVascular Sonography
No246XS1301XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist CardiovascularSonography
No2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonography