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General NPI Number Information
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NPI Number | 1992211767
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Entity Type | Individual
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Provider Name | JESSE POLANCO PT, DPT
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Gender | Male
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Dates
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Enumeration Date | 12/15/2017
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Last Update Date | 10/24/2019
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Provider Practice Location Address
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Address Line | 4019 HENDERSON BLVD
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City | TAMPA
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State | FL
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Zip | 33629-4939
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Country | US
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Telephone | 813-395-0018
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Fax |
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Provider Business Mailing Address
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Address Line | 100 W 169TH ST APT 2
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City | BRONX
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State | NY
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Zip | 10452-2808
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Country | US
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Telephone | 917-601-7515
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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 | 2251X0800X
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Taxonomy Name | Orthopedic Physical Therapist
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License Number | PT33217
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License Number State | FL
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