Provider Demographics
NPI:1205042629
Name:LEAVITT, JACQUELINE LEE (PT)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:LEE
Last Name:LEAVITT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 BROOME ST APT 27
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-6405
Mailing Address - Country:US
Mailing Address - Phone:646-613-0474
Mailing Address - Fax:
Practice Address - Street 1:177 PRINCE ST #407
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10012
Practice Address - Country:US
Practice Address - Phone:917-309-4070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024576225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist