Provider Demographics
NPI:1609922145
Name:NICODEMO-CAPRA, JENNIFER (MA, PT)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:NICODEMO-CAPRA
Suffix:
Gender:F
Credentials:MA, PT
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:CAPRA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA,PT
Mailing Address - Street 1:2 WALTON WAY
Mailing Address - Street 2:LIGHTHOUSE PHYSICAL THERAPY, P.C.
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-1001
Mailing Address - Country:US
Mailing Address - Phone:631-440-7678
Mailing Address - Fax:631-331-0320
Practice Address - Street 1:2 WALTON WAY
Practice Address - Street 2:LIGHTHOUSE PHYSICAL THERAPY, P.C.
Practice Address - City:CORAM
Practice Address - State:NY
Practice Address - Zip Code:11727-1001
Practice Address - Country:US
Practice Address - Phone:631-440-7678
Practice Address - Fax:631-331-0320
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015513-1225100000X
NY015513225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02486193Medicaid
NYA100063588OtherMEDICARE GROUP