Provider Demographics
NPI:1235296161
Name:JELLINICK, LORI LYNN (PT)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:LYNN
Last Name:JELLINICK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:LORI
Other - Middle Name:LYNN
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1127 STALEY RD
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:14072-2112
Mailing Address - Country:US
Mailing Address - Phone:716-775-1717
Mailing Address - Fax:
Practice Address - Street 1:462 GRIDER ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-3021
Practice Address - Country:US
Practice Address - Phone:716-898-4687
Practice Address - Fax:716-898-3259
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012133-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist