Provider Demographics
NPI:1871282053
Name:ADDEO, JACQUELYN (LMT)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:ADDEO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 QUEBEC DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-3870
Mailing Address - Country:US
Mailing Address - Phone:631-896-3247
Mailing Address - Fax:
Practice Address - Street 1:340 VETERANS MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-4300
Practice Address - Country:US
Practice Address - Phone:631-776-3019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-03
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030373-01225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist