Provider Demographics
NPI:1346822426
Name:MCCULLOUGH, JACLYN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:
Other - Last Name:FEFFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1128 STATE ROUTE 17K STE 3
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:NY
Mailing Address - Zip Code:12549-2270
Mailing Address - Country:US
Mailing Address - Phone:845-769-7777
Mailing Address - Fax:845-769-0007
Practice Address - Street 1:1128 NY-17K
Practice Address - Street 2:SUITE 3
Practice Address - City:MONTGOMERY
Practice Address - State:NY
Practice Address - Zip Code:12549-1254
Practice Address - Country:US
Practice Address - Phone:845-769-7777
Practice Address - Fax:845-769-0007
Is Sole Proprietor?:No
Enumeration Date:2021-04-27
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP20288225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist