Provider Demographics
NPI:1114430220
Name:PLONSKI, JACKLYN ROSE (DPT)
Entity Type:Individual
Prefix:
First Name:JACKLYN
Middle Name:ROSE
Last Name:PLONSKI
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 W MAIN ST STE 340
Mailing Address - Street 2:
Mailing Address - City:BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11702-3009
Mailing Address - Country:US
Mailing Address - Phone:631-661-3180
Mailing Address - Fax:631-661-3183
Practice Address - Street 1:400 W MAIN ST STE 340
Practice Address - Street 2:
Practice Address - City:BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11702-3009
Practice Address - Country:US
Practice Address - Phone:631-661-3180
Practice Address - Fax:631-661-3183
Is Sole Proprietor?:No
Enumeration Date:2017-11-10
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042432225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist