Provider Demographics
NPI:1619294188
Name:POVEROMO, JESSIE (PSYD)
Entity type:Individual
Prefix:DR
First Name:JESSIE
Middle Name:
Last Name:POVEROMO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 N VILLAGE AVE STE 216
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-3701
Mailing Address - Country:US
Mailing Address - Phone:516-665-9669
Mailing Address - Fax:
Practice Address - Street 1:165 N VILLAGE AVE STE 216
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-3701
Practice Address - Country:US
Practice Address - Phone:516-665-9669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-23
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018490103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral