Provider Demographics
NPI:1639444185
Name:MANSOUR, JACKLEEN FARAG (PT)
Entity Type:Individual
Prefix:
First Name:JACKLEEN
Middle Name:FARAG
Last Name:MANSOUR
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 1:604 SPRINGVIEW DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48307-6070
Mailing Address - Country:US
Mailing Address - Phone:248-650-1984
Mailing Address - Fax:248-650-1994
Practice Address - Street 1:1050 W UNIVERSITY DR
Practice Address - Street 2:SUITE 3
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-1877
Practice Address - Country:US
Practice Address - Phone:248-650-1984
Practice Address - Fax:248-650-1994
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-16
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501012928225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist