Provider Demographics
NPI:1043240898
Name:JACK, MICHELLE (PT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:JACK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:145 ALBANY AVE
Mailing Address - Street 2:APT 4A
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11213-1701
Mailing Address - Country:US
Mailing Address - Phone:212-580-0125
Mailing Address - Fax:212-580-0860
Practice Address - Street 1:21 W 86TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-3616
Practice Address - Country:US
Practice Address - Phone:212-580-0125
Practice Address - Fax:212-580-0860
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028207225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist