Provider Demographics
NPI:1417186123
Name:JIM, JACQUELINE A (OT/L)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:A
Last Name:JIM
Suffix:
Gender:F
Credentials:OT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3205 GREEN MDW
Mailing Address - Street 2:
Mailing Address - City:BALDWINSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13027-8929
Mailing Address - Country:US
Mailing Address - Phone:315-857-4481
Mailing Address - Fax:
Practice Address - Street 1:3205 GREEN MDW
Practice Address - Street 2:
Practice Address - City:BALDWINSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13027
Practice Address - Country:US
Practice Address - Phone:315-857-4481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-02
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008281-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist