Healthcare Provider Details

I. General information

NPI: 1427364793
Provider Name (Legal Business Name): JESSICA S LAKE DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2010
Last Update Date: 08/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 BRADHURST AVE
VALHALLA NY
10595-1637
US

IV. Provider business mailing address

37 HAMILTON PL APT MD
TARRYTOWN NY
10591-3425
US

V. Phone/Fax

Practice location:
  • Phone: 914-592-7555
  • Fax:
Mailing address:
  • Phone: 631-835-3432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number033013
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: