Provider Demographics
NPI:1679094767
Name:KOPACK, JACQUELINE (PT)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:KOPACK
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 1:75 PINE AVE
Mailing Address - Street 2:
Mailing Address - City:RICHBORO
Mailing Address - State:PA
Mailing Address - Zip Code:18954-1511
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 PAOLI POINTE DR
Practice Address - Street 2:
Practice Address - City:PAOLI
Practice Address - State:PA
Practice Address - Zip Code:19301-2104
Practice Address - Country:US
Practice Address - Phone:610-296-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-29
Last Update Date:2017-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT007767L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist