Provider Demographics
NPI:1588986954
Name:WOOD, JESSICA (RN, PNP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:WOOD
Suffix:
Gender:F
Credentials:RN, PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:363 ROUTE 111 STE 103
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-4750
Mailing Address - Country:US
Mailing Address - Phone:631-488-0612
Mailing Address - Fax:631-629-6762
Practice Address - Street 1:363 ROUTE 111 STE 103
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-4750
Practice Address - Country:US
Practice Address - Phone:631-488-0612
Practice Address - Fax:631-629-6762
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-25
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY590317163W00000X
NY382909363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse