Provider Demographics
NPI:1467429845
Name:MARSHALL, JENNIFER ELAINE (PT)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ELAINE
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:178 CLIZBE AVE
Mailing Address - Street 2:
Mailing Address - City:AMSTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12010-2935
Mailing Address - Country:US
Mailing Address - Phone:518-842-1425
Mailing Address - Fax:518-842-1706
Practice Address - Street 1:178 CLIZBE AVE
Practice Address - Street 2:
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010-2935
Practice Address - Country:US
Practice Address - Phone:518-842-1425
Practice Address - Fax:518-842-1706
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2009-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0183431225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
141637577OtherWORKERS COMP
000490155008OtherBLUE SHIELD
QQ3542OtherBS
NY01940665Medicaid
10027745OtherCDPHP
141637577OtherEMPIRE BC BS
141637577OtherCOMMERCIAL
6008747OtherMVP
141637577OtherCOMMERCIAL
NY01940665Medicaid
S89763Medicare UPIN