Provider Demographics
NPI:1659898765
Name:IVATOROV, JESSICA (PT,DPT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:IVATOROV
Suffix:
Gender:F
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 1:1243 WOODROW RD STE 321
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10309-1725
Mailing Address - Country:US
Mailing Address - Phone:718-844-5350
Mailing Address - Fax:718-966-0005
Practice Address - Street 1:1 HANSON PL STE 401
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11243-2907
Practice Address - Country:US
Practice Address - Phone:718-230-0631
Practice Address - Fax:718-221-1009
Is Sole Proprietor?:No
Enumeration Date:2017-08-29
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042053225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist