Provider Demographics
NPI:1710219639
Name:REA, JACQUELINE KINLEY (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:KINLEY
Last Name:REA
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 1:333 W CORDOVA RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-1850
Mailing Address - Country:US
Mailing Address - Phone:505-984-9101
Mailing Address - Fax:505-984-8998
Practice Address - Street 1:333 W CORDOVA RD
Practice Address - Street 2:SUITE 100
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-1850
Practice Address - Country:US
Practice Address - Phone:505-984-9101
Practice Address - Fax:505-984-8998
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-02
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3710225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist