Provider Demographics
NPI:1720722960
Name:BACCAGLINI, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BACCAGLINI
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 1:34 DARTMOUTH ST
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-2411
Mailing Address - Country:US
Mailing Address - Phone:516-672-8810
Mailing Address - Fax:
Practice Address - Street 1:801 MERRICK AVE
Practice Address - Street 2:
Practice Address - City:EAST MEADOW
Practice Address - State:NY
Practice Address - Zip Code:11554-4748
Practice Address - Country:US
Practice Address - Phone:516-723-2663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-25
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046005225100000X
CA301086225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist