Provider Demographics
NPI:1134580624
Name:JACK, JOYCE (PTA)
Entity type:Individual
Prefix:MS
First Name:JOYCE
Middle Name:
Last Name:JACK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7809 153RD AVE
Mailing Address - Street 2:1D-1
Mailing Address - City:HOWARD BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11414-1771
Mailing Address - Country:US
Mailing Address - Phone:718-249-3744
Mailing Address - Fax:
Practice Address - Street 1:7809 153RD AVE
Practice Address - Street 2:1D-1
Practice Address - City:HOWARD BEACH
Practice Address - State:NY
Practice Address - Zip Code:11414-1771
Practice Address - Country:US
Practice Address - Phone:718-249-3744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-11
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002628-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant