Provider Demographics
NPI:1225255912
Name:NITKA, JACQUELINE DIANE (LMT)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:DIANE
Last Name:NITKA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 PANORAMA TRL
Mailing Address - Street 2:BLDG 1
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14625-2404
Mailing Address - Country:US
Mailing Address - Phone:585-586-7630
Mailing Address - Fax:585-586-7695
Practice Address - Street 1:625 PANORAMA TRL
Practice Address - Street 2:BLDG 1
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14625-2404
Practice Address - Country:US
Practice Address - Phone:585-586-7630
Practice Address - Fax:585-586-7695
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015390225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist