Provider Demographics
NPI:1609583145
Name:DISTEFANO, JASON (DPT)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:DISTEFANO
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 1:1311 MAMARONECK AVE STE 140
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10605-5224
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:389 FORT SALONGA RD
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-3089
Practice Address - Country:US
Practice Address - Phone:631-261-0444
Practice Address - Fax:631-261-3112
Is Sole Proprietor?:No
Enumeration Date:2022-11-03
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050122225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist