Provider Demographics
NPI:1225267065
Name:WORTH, JACQUELYN DANA (PT)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:DANA
Last Name:WORTH
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 1:1395 LEXINGTON AVE
Mailing Address - Street 2:92 STREET Y MEZZANINE LEVEL
Mailing Address - City:NYC
Mailing Address - State:NY
Mailing Address - Zip Code:10128
Mailing Address - Country:US
Mailing Address - Phone:646-707-0400
Mailing Address - Fax:
Practice Address - Street 1:1395 LEXINGTON AVE
Practice Address - Street 2:92 STREET Y MEZZANINE LEVEL
Practice Address - City:NYC
Practice Address - State:NY
Practice Address - Zip Code:10128
Practice Address - Country:US
Practice Address - Phone:646-707-0400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-14
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017016225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400015498Medicare PIN