Provider Demographics
NPI:1477514677
Name:FARRELL, JACQUILEEN M (PT)
Entity Type:Individual
Prefix:
First Name:JACQUILEEN
Middle Name:M
Last Name:FARRELL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JACQUILEEN
Other - Middle Name:M
Other - Last Name:HOMACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:5100 W TAFT RD
Mailing Address - Street 2:SUITE 2K
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-3807
Mailing Address - Country:US
Mailing Address - Phone:315-452-2200
Mailing Address - Fax:315-452-2204
Practice Address - Street 1:5100 W TAFT RD
Practice Address - Street 2:SUITE 2K
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-3807
Practice Address - Country:US
Practice Address - Phone:315-452-2200
Practice Address - Fax:315-452-2204
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027850225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRA9913Medicare ID - Type UnspecifiedMEDICARE NUMBER