Provider Demographics
NPI:1962982496
Name:BLACKWOOD, JENA RAE (DPT)
Entity type:Individual
Prefix:
First Name:JENA
Middle Name:RAE
Last Name:BLACKWOOD
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:62 CLERMONT AVE APT 605
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11205-2575
Mailing Address - Country:US
Mailing Address - Phone:917-565-7417
Mailing Address - Fax:
Practice Address - Street 1:LIU CENTER FOR PHYSICAL REHABILITATION
Practice Address - Street 2:1 UNIVERSITY PLAZA, HS 201
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201
Practice Address - Country:US
Practice Address - Phone:718-780-4531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043313225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist