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General NPI Number Information
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NPI Number | 1083198790
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Entity Type | Individual
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Provider Name | JENALYN D VERGARA PT
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Gender | Female
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Dates
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Enumeration Date | 09/18/2018
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Last Update Date | 09/18/2018
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Provider Practice Location Address
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Address Line | 186 JERRY BROWNE RD
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City | MYSTIC
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State | CT
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Zip | 06355-4004
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Country | US
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Telephone | 860-572-5675
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Fax |
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Provider Business Mailing Address
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Address Line | 29 ENSIGN DR
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City | MYSTIC
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State | CT
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Zip | 06355-1530
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Country | US
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Telephone | 631-882-5464
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 008043
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License Number State | CT
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