Basic Information
| Provider Information | |||||||||
| NPI: | 1689652703 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JASKOVIAK | ||||||||
| FirstName: | KENT | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 630 PLANTATION ST | ||||||||
| Address2: | WOT 12TH FLOOR ATTN: PHYSICIAN SERVICES | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083685529 | ||||||||
| FaxNumber: | 5083685530 | ||||||||
| Practice Location | |||||||||
| Address1: | 135 GOLD STAR BLVD | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088569510 | ||||||||
| FaxNumber: | 5088531907 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 13115 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 7248629 | 01 | AETNA US HEALTHCARE | OTHER | Y68470 | 01 | MEDICARE B | OTHER | 2779432 | 01 | CIGNA HEALTH PLAN | OTHER | Y67947 | 01 | BLUE SHIELD HMO BLUE | OTHER | 0318922 | 01 | MEDICAID WELFARE | OTHER | 0318922 | 05 | MA | MEDICAID | 2779432001 | 01 | CIGNA PAL ID | OTHER | AA4052 | 01 | HARVARD PILGRIM HEALTHCAR | OTHER | 35481155 | 01 | CIGNA HEALTHSOURCE | OTHER | 43205 | 01 | FALLON COMMUNITY HEALTH P | OTHER | Y67947 | 01 | BLUE CARE ELECT | OTHER | Y67947 | 01 | BLUE SHIELD INDEMNITY | OTHER |