Basic Information
| Provider Information | |||||||||
| NPI: | 1639833502 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTUSCELLO | ||||||||
| FirstName: | JENNA | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1375 BUNGALOW LN | ||||||||
| Address2: | |||||||||
| City: | MATTITUCK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 119522282 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6319034254 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7555 MAIN RD | ||||||||
| Address2: | |||||||||
| City: | MATTITUCK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 119521516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6312988642 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2021 | ||||||||
| LastUpdateDate: | 10/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 112693 | NY | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 112693 | 01 | NY | SOCIAL WORK LICENSE | OTHER |