Provider Demographics
NPI:1558348987
Name:THEEMAN, ELIZABETH JACKSTADT (MS, PT)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:JACKSTADT
Last Name:THEEMAN
Suffix:
Gender:F
Credentials:MS, PT
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:N
Other - Last Name:JACKSTADT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSPT
Mailing Address - Street 1:39 COURT ST
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901
Mailing Address - Country:US
Mailing Address - Phone:518-563-0267
Mailing Address - Fax:518-563-1633
Practice Address - Street 1:39 COURT ST.
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901
Practice Address - Country:US
Practice Address - Phone:518-563-0267
Practice Address - Fax:518-563-1633
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025769225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ32721Medicare UPIN