Provider Demographics
NPI:1427364793
Name:LAKE, JESSICA S (DPT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:S
Last Name:LAKE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 HAMILTON PL
Mailing Address - Street 2:APT MD
Mailing Address - City:TARRYTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10591-3425
Mailing Address - Country:US
Mailing Address - Phone:631-835-3432
Mailing Address - Fax:
Practice Address - Street 1:95 BRADHURST AVE
Practice Address - Street 2:
Practice Address - City:VALHALLA
Practice Address - State:NY
Practice Address - Zip Code:10595-1637
Practice Address - Country:US
Practice Address - Phone:914-592-7555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-25
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033013225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist