Provider Demographics
NPI:1609818376
Name:GAMBINO, JACQUELINE B (PT)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:B
Last Name:GAMBINO
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 1:11 KILBURN ST
Mailing Address - Street 2:THE BODY CENTER
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-4750
Mailing Address - Country:US
Mailing Address - Phone:802-865-9500
Mailing Address - Fax:802-865-9559
Practice Address - Street 1:11 KILBURN ST
Practice Address - Street 2:THE BODY CENTER
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-4750
Practice Address - Country:US
Practice Address - Phone:802-865-9500
Practice Address - Fax:802-865-9559
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT375545OtherMVP
VT1007598Medicaid
VT7792624OtherCIGNA
VT48377OtherTVHP/BC BS
VT4693301OtherFLETCHER ALLEN PREFERRED
VT4693301OtherFLETCHER ALLEN PREFERRED