Provider Demographics
NPI:1699184861
Name:COLLENTRO, JACLYN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:COLLENTRO
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 PEARL ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01772-1923
Mailing Address - Country:US
Mailing Address - Phone:203-520-4101
Mailing Address - Fax:
Practice Address - Street 1:1123 CENTRAL ST
Practice Address - Street 2:
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453-4960
Practice Address - Country:US
Practice Address - Phone:617-536-1161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-12
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1248080225100000X
MA23426225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist