Provider Demographics
NPI:1083198790
Name:VERGARA, JENALYN D (PT)
Entity type:Individual
Prefix:
First Name:JENALYN
Middle Name:D
Last Name:VERGARA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 ENSIGN DR
Mailing Address - Street 2:
Mailing Address - City:MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06355-1530
Mailing Address - Country:US
Mailing Address - Phone:631-882-5464
Mailing Address - Fax:
Practice Address - Street 1:186 JERRY BROWNE RD
Practice Address - Street 2:
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355-4004
Practice Address - Country:US
Practice Address - Phone:860-572-5675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT008043225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty