Healthcare Provider Details

I. General information

NPI: 1811385958
Provider Name (Legal Business Name): JESSICA KSIAZEK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2014
Last Update Date: 12/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 CYNTHIA LN
MIDDLETOWN CT
06457-2140
US

IV. Provider business mailing address

65 CYNTHIA LN
MIDDLETOWN CT
06457-2140
US

V. Phone/Fax

Practice location:
  • Phone: 860-344-8121
  • Fax:
Mailing address:
  • Phone: 860-301-9689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number10290
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: