Provider Demographics
NPI:1285058297
Name:JAGODZINSKI, KATELYNN
Entity type:Individual
Prefix:
First Name:KATELYNN
Middle Name:
Last Name:JAGODZINSKI
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 1:12 LAURIE LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH SALEM
Mailing Address - State:NY
Mailing Address - Zip Code:10590-1700
Mailing Address - Country:US
Mailing Address - Phone:845-625-4614
Mailing Address - Fax:
Practice Address - Street 1:12 LAURIE LN
Practice Address - Street 2:
Practice Address - City:SOUTH SALEM
Practice Address - State:NY
Practice Address - Zip Code:10590-1700
Practice Address - Country:US
Practice Address - Phone:845-625-4614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-11
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001678-12255A2300X
CT0005332255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer