Provider Demographics
NPI:1689944670
Name:SARGALIS, JESSICA LYNN (MPT)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LYNN
Last Name:SARGALIS
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 PINE ST
Mailing Address - Street 2:
Mailing Address - City:BROADALBIN
Mailing Address - State:NY
Mailing Address - Zip Code:12025-3128
Mailing Address - Country:US
Mailing Address - Phone:518-954-2500
Mailing Address - Fax:518-954-2509
Practice Address - Street 1:100 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:BROADALBIN
Practice Address - State:NY
Practice Address - Zip Code:12025-2193
Practice Address - Country:US
Practice Address - Phone:518-954-2645
Practice Address - Fax:518-954-2659
Is Sole Proprietor?:No
Enumeration Date:2012-01-06
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022845-12251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1538212907OtherBROADALBIN-PERTH CSD NPI NUMBER
NY01414337Medicaid
251300000XOtherBROADALBIN-PERTH CSD TAXONOMY NUMBER