Provider Demographics
NPI:1316203946
Name:JUMP START THERAPY PLACE
Entity Type:Organization
Organization Name:JUMP START THERAPY PLACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:YELENA
Authorized Official - Middle Name:
Authorized Official - Last Name:NEMTSOVA
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:917-622-2612
Mailing Address - Street 1:4131 RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-5633
Mailing Address - Country:US
Mailing Address - Phone:718-351-0308
Mailing Address - Fax:
Practice Address - Street 1:4131 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-5633
Practice Address - Country:US
Practice Address - Phone:718-351-0308
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-09
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY05516225100000X
NY006852225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty