Provider Demographics
NPI:1053738542
Name:CANDELASA, JINGLE
Entity type:Individual
Prefix:
First Name:JINGLE
Middle Name:
Last Name:CANDELASA
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 1:800 VICTORY BLVD APT 5L
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-3710
Mailing Address - Country:US
Mailing Address - Phone:646-455-7125
Mailing Address - Fax:
Practice Address - Street 1:800 VICTORY BLVD. APT 5L
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301
Practice Address - Country:US
Practice Address - Phone:646-455-7125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-24
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031426-12251G0304X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics