Basic Information
| Provider Information | |||||||||
| NPI: | 1457778938 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DELLOSTRITTO | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA, AT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1044 BELMONT AVE | ||||||||
| Address2: | |||||||||
| City: | YOUNGSTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 445041006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304803990 | ||||||||
| FaxNumber: | 3304803522 | ||||||||
| Practice Location | |||||||||
| Address1: | 3730 TABS DR | ||||||||
| Address2: | |||||||||
| City: | UNIONTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44685 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3305630618 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2014 | ||||||||
| LastUpdateDate: | 07/23/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 003551 | OH | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 363A00000X | 50.0048272RX | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0211325 | 05 | OH | MEDICAID |