Provider Demographics
NPI:1235230400
Name:SULLIVAN, JACQUELINE DENISE (PTA ATRIC)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:DENISE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PTA ATRIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:785 MANRESA
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-7237
Mailing Address - Country:US
Mailing Address - Phone:314-921-5253
Mailing Address - Fax:
Practice Address - Street 1:15884 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MO
Practice Address - Zip Code:63011
Practice Address - Country:US
Practice Address - Phone:636-391-5400
Practice Address - Fax:636-394-9674
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000161113225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant