Provider Demographics
NPI:1316369598
Name:MACKINNON, JANICE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:
Last Name:MACKINNON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 WAVERLY OAKS RD BLDG 3
Mailing Address - Street 2:SUITE 305
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02452-8448
Mailing Address - Country:US
Mailing Address - Phone:781-894-6564
Mailing Address - Fax:
Practice Address - Street 1:411 WAVERLY OAKS RD BLDG 3
Practice Address - Street 2:SUITE 305
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02452-8448
Practice Address - Country:US
Practice Address - Phone:781-894-6564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-07
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4632225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist