=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457659690
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JUMP START PHYSICAL THERAPY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2011
-----------------------------------------------------
Last Update Date | 03/12/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23 W GLANN RD
-----------------------------------------------------
City | APALACHIN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13732-4026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-725-0889
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23 W GLANN RD
-----------------------------------------------------
City | APALACHIN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13732-4026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-725-0889
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST/ OWNER
-----------------------------------------------------
Name | MRS. JESSICA MARIE REINARTZ
-----------------------------------------------------
Credential | PT, DPT
-----------------------------------------------------
Telephone | 607-725-0889
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number | 017408
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------