Healthcare Provider Details

I. General information

NPI: 1164255311
Provider Name (Legal Business Name): JACOB DAVID KOWALEWSKI PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2024
Last Update Date: 08/22/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 ROCKEFELLER RD
DELMAR NY
12054-2221
US

IV. Provider business mailing address

148 KERN RD
COWLESVILLE NY
14037-9736
US

V. Phone/Fax

Practice location:
  • Phone: 518-439-8116
  • Fax:
Mailing address:
  • Phone: 716-525-0882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number42191
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number050814
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: