Healthcare Provider Details

I. General information

NPI: 1821556895
Provider Name (Legal Business Name): JORDAN PLACELLA DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2019
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 NORTHERN BLVD STE 11
GREAT NECK NY
11021-4802
US

IV. Provider business mailing address

93 JASMINE LN
EAST NORTHPORT NY
11731-3617
US

V. Phone/Fax

Practice location:
  • Phone: 516-829-0030
  • Fax: 516-466-7723
Mailing address:
  • Phone: 631-742-7111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number043468
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: