Provider Demographics
NPI:1356815393
Name:AUGUSTINE, JACQUELINE (PTA)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:
Last Name:AUGUSTINE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:422 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-5768
Mailing Address - Country:US
Mailing Address - Phone:330-268-2801
Mailing Address - Fax:
Practice Address - Street 1:422 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-5768
Practice Address - Country:US
Practice Address - Phone:330-268-2801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-13
Last Update Date:2019-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA011842225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant