Provider Demographics
NPI:1629808563
Name:MAGIONCALDA, JESSICA MARIE (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:MAGIONCALDA
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 CIRCLE CT
Mailing Address - Street 2:
Mailing Address - City:FARMINGVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11738-2309
Mailing Address - Country:US
Mailing Address - Phone:631-459-0344
Mailing Address - Fax:
Practice Address - Street 1:100 GRANNY RD STE 1
Practice Address - Street 2:
Practice Address - City:FARMINGVILLE
Practice Address - State:NY
Practice Address - Zip Code:11738-2879
Practice Address - Country:US
Practice Address - Phone:631-696-4957
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-06
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY405989363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health