Provider Demographics
NPI:1568931160
Name:KINGSLEY, JEREMY D (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:D
Last Name:KINGSLEY
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1075 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:NY
Mailing Address - Zip Code:14580-2982
Mailing Address - Country:US
Mailing Address - Phone:585-671-3770
Mailing Address - Fax:
Practice Address - Street 1:1075 RIDGE RD
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:NY
Practice Address - Zip Code:14580-2982
Practice Address - Country:US
Practice Address - Phone:585-671-3770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-13
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043737225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY043737Medicaid