Provider Demographics
NPI:1689652703
Name:JASKOVIAK, KENT P (PT)
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:P
Last Name:JASKOVIAK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:630 PLANTATION ST
Mailing Address - Street 2:WOT 12TH FLOOR ATTN: PHYSICIAN SERVICES
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605
Mailing Address - Country:US
Mailing Address - Phone:508-368-5529
Mailing Address - Fax:508-368-5530
Practice Address - Street 1:135 GOLD STAR BLVD
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01606
Practice Address - Country:US
Practice Address - Phone:508-856-9510
Practice Address - Fax:508-853-1907
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA13115225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
7248629OtherAETNA US HEALTHCARE
Y68470OtherMEDICARE B
2779432OtherCIGNA HEALTH PLAN
Y67947OtherBLUE SHIELD HMO BLUE
0318922OtherMEDICAID WELFARE
MA0318922Medicaid
2779432001OtherCIGNA PAL ID
AA4052OtherHARVARD PILGRIM HEALTHCAR
35481155OtherCIGNA HEALTHSOURCE
43205OtherFALLON COMMUNITY HEALTH P
Y67947OtherBLUE CARE ELECT
Y67947OtherBLUE SHIELD INDEMNITY
Y67947OtherBLUE SHIELD HMO BLUE