Healthcare Provider Details

I. General information

NPI: 1235083064
Provider Name (Legal Business Name): JONALYN ANTONIO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2026
Last Update Date: 02/26/2026
Certification Date: 02/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

587 JAYNE BLVD
PORT JEFFERSON STATION NY
11776-2946
US

IV. Provider business mailing address

587 JAYNE BLVD
PORT JEFFERSON STATION NY
11776-2946
US

V. Phone/Fax

Practice location:
  • Phone: 619-522-4007
  • Fax:
Mailing address:
  • Phone: 619-522-4007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number011154
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: