Provider Demographics
NPI:1164975694
Name:OATES, JACQUELINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:OATES
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 1:15 SIERRA DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH EASTON
Mailing Address - State:MA
Mailing Address - Zip Code:02375-1251
Mailing Address - Country:US
Mailing Address - Phone:508-802-1223
Mailing Address - Fax:
Practice Address - Street 1:1080 DAY HILL RD
Practice Address - Street 2:SUITE 2
Practice Address - City:WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06095-1781
Practice Address - Country:US
Practice Address - Phone:860-298-8442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-02
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT11058225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist