Provider Demographics
NPI:1376687434
Name:GEORGE, JACQUELINE ELAINE (ATC)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ELAINE
Last Name:GEORGE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1408 ALVIN AVE
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-2901
Mailing Address - Country:US
Mailing Address - Phone:570-322-3576
Mailing Address - Fax:
Practice Address - Street 1:701 CEMETERY STREET
Practice Address - Street 2:
Practice Address - City:JERSEY SHORE
Practice Address - State:PA
Practice Address - Zip Code:17740
Practice Address - Country:US
Practice Address - Phone:570-398-7170
Practice Address - Fax:570-398-5612
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART000126A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer