Provider Demographics
NPI:1831642396
Name:GAMACHE, JACLYN A (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:A
Last Name:GAMACHE
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 1:794 HITCHCOCK RD
Mailing Address - Street 2:
Mailing Address - City:PITTSFORD
Mailing Address - State:VT
Mailing Address - Zip Code:05763-9544
Mailing Address - Country:US
Mailing Address - Phone:207-632-4030
Mailing Address - Fax:
Practice Address - Street 1:1 SCALE AVE
Practice Address - Street 2:BUILDING 18, SUITE 32
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4452
Practice Address - Country:US
Practice Address - Phone:802-855-8068
Practice Address - Fax:802-855-8436
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-01
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040.0121765225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT13865603OtherCAQH PROVIDER ID