Provider Demographics
NPI:1528369675
Name:GUSTAFSON, JEAN M (PT)
Entity Type:Individual
Prefix:MS
First Name:JEAN
Middle Name:M
Last Name:GUSTAFSON
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 1:623 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:SCOTIA
Mailing Address - State:NY
Mailing Address - Zip Code:12302-1431
Mailing Address - Country:US
Mailing Address - Phone:518-370-3642
Mailing Address - Fax:
Practice Address - Street 1:80 NORTH MAIN STREET
Practice Address - Street 2:MAYFIELD ELEMENTARY SCHOOL
Practice Address - City:MAYFIELD
Practice Address - State:NY
Practice Address - Zip Code:12117
Practice Address - Country:US
Practice Address - Phone:518-661-5352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-05
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010990-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist