Provider Demographics
NPI:1457688905
Name:SCOTT, JERILEE SHAKIRAH (MPT)
Entity Type:Individual
Prefix:
First Name:JERILEE
Middle Name:SHAKIRAH
Last Name:SCOTT
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 NEW DORP LN
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-2320
Mailing Address - Country:US
Mailing Address - Phone:718-370-3500
Mailing Address - Fax:718-979-5236
Practice Address - Street 1:4013 AVENUE U
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-5117
Practice Address - Country:US
Practice Address - Phone:718-692-4100
Practice Address - Fax:718-692-0089
Is Sole Proprietor?:No
Enumeration Date:2009-11-04
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0316761225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400032406Medicare PIN