Provider Demographics
NPI:1326403700
Name:SASALA, JACQUELINE
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:
Last Name:SASALA
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 1:14 MORRIS ST
Mailing Address - Street 2:
Mailing Address - City:SEWAREN
Mailing Address - State:NJ
Mailing Address - Zip Code:07077-1023
Mailing Address - Country:US
Mailing Address - Phone:732-404-7051
Mailing Address - Fax:
Practice Address - Street 1:14 MORRIS ST
Practice Address - Street 2:
Practice Address - City:SEWAREN
Practice Address - State:NJ
Practice Address - Zip Code:07077-1023
Practice Address - Country:US
Practice Address - Phone:732-404-7051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-29
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT002182002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer