Provider Demographics
NPI:1326179888
Name:ECKARDT, JENNIFER HOMER (MS PT)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:HOMER
Last Name:ECKARDT
Suffix:
Gender:F
Credentials:MS PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 BLACKBERRY RD
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090-3004
Mailing Address - Country:US
Mailing Address - Phone:315-622-2791
Mailing Address - Fax:
Practice Address - Street 1:124 US ROUTE 11
Practice Address - Street 2:
Practice Address - City:CENTRAL SQUARE
Practice Address - State:NY
Practice Address - Zip Code:13036-9760
Practice Address - Country:US
Practice Address - Phone:315-668-0123
Practice Address - Fax:315-668-0124
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029073-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBA0291Medicare ID - Type UnspecifiedGROUP MEDICARE #