Provider Demographics
NPI:1346269891
Name:WESLEY, JESSICA (PT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:WESLEY
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 1:120 NEWHAM AVE
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-5624
Mailing Address - Country:US
Mailing Address - Phone:631-813-2143
Mailing Address - Fax:888-552-6176
Practice Address - Street 1:5499 NESCONSET HWY
Practice Address - Street 2:
Practice Address - City:MOUNT SINAI
Practice Address - State:NY
Practice Address - Zip Code:11766-2003
Practice Address - Country:US
Practice Address - Phone:631-331-3910
Practice Address - Fax:888-552-6184
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025830225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ08511Medicare PIN
NYQ08511Medicare Oscar/Certification