Provider Demographics
NPI:1619629268
Name:JACQUES, LESLY
Entity Type:Individual
Prefix:
First Name:LESLY
Middle Name:
Last Name:JACQUES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1446 E 103RD ST UNIT 2ND
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-4514
Mailing Address - Country:US
Mailing Address - Phone:718-377-5000
Mailing Address - Fax:
Practice Address - Street 1:1446 E 103RD ST UNIT 2ND
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-4514
Practice Address - Country:US
Practice Address - Phone:718-377-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-25
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006633225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant