Provider Demographics
NPI:1770319519
Name:JACKOVITZ, MARCUS VINICIUS (DPT)
Entity type:Individual
Prefix:DR
First Name:MARCUS
Middle Name:VINICIUS
Last Name:JACKOVITZ
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9703 SANDPIPER LN
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-6321
Mailing Address - Country:US
Mailing Address - Phone:561-303-7736
Mailing Address - Fax:
Practice Address - Street 1:93 WYNWOOD DR
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-6149
Practice Address - Country:US
Practice Address - Phone:561-303-7736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-09
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT14190225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist