Individual
JAKE T BROCCOLO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DPT
Contact information
Practice address
1401 DOUGLAS AVE, NORTH PROVIDENCE, RI 02904-4058
(401) 726-7100
Mailing address
4 RICHMOND SQ, PROVIDENCE, RI 02906-5117
(401) 433-4172
(401) 433-0612
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
PT03093
RI
225100000X
Physical Therapist
PTL88684
MA
Other
Enumeration date
08/10/2018
Last updated
01/30/2026
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