Provider Demographics
NPI:1265934475
Name:JAYAWANT, NIKETA KEDAR
Entity type:Individual
Prefix:
First Name:NIKETA
Middle Name:KEDAR
Last Name:JAYAWANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1760 REVERE BEACH PKWY APT 518
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:MA
Mailing Address - Zip Code:02149-5969
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 GOVERNORS AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-1644
Practice Address - Country:US
Practice Address - Phone:781-391-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-03
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA23502225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist