Provider Demographics
NPI:1548681455
Name:YOUNGHANS, JACKIE (DPT)
Entity type:Individual
Prefix:MR
First Name:JACKIE
Middle Name:
Last Name:YOUNGHANS
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 1:825 E GATE BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-2124
Mailing Address - Country:US
Mailing Address - Phone:516-227-5344
Mailing Address - Fax:516-227-5339
Practice Address - Street 1:825 E GATE BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-2124
Practice Address - Country:US
Practice Address - Phone:516-227-5344
Practice Address - Fax:516-227-5339
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-18
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025634225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY451536823Medicare UPIN
NY451536823Medicare PIN