Healthcare Provider Details

I. General information

NPI: 1265934475
Provider Name (Legal Business Name): NIKETA KEDAR JAYAWANT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2018
Last Update Date: 06/30/2020
Certification Date: 06/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 GOVERNORS AVE
MEDFORD MA
02155-1644
US

IV. Provider business mailing address

1760 REVERE BEACH PKWY APT 518
EVERETT MA
02149-5969
US

V. Phone/Fax

Practice location:
  • Phone: 781-391-5400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number23502
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: