Provider Demographics
NPI:1992764716
Name:RAI, JENNIFER NICOLLA (PT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:NICOLLA
Last Name:RAI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:NICOLLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:415 N CRESCENT DR
Mailing Address - Street 2:SUITE 130
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-4860
Mailing Address - Country:US
Mailing Address - Phone:310-273-0877
Mailing Address - Fax:310-273-1189
Practice Address - Street 1:415 N CRESCENT DR
Practice Address - Street 2:SUITE 130
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-4860
Practice Address - Country:US
Practice Address - Phone:310-273-0877
Practice Address - Fax:310-273-1189
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023503-1225100000X
CA34072225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400139953Medicare PIN