Provider Demographics
NPI:1871023697
Name:BIRDSALL, JACQUELINE (DPT)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:BIRDSALL
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:RISTOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:400 BOSTON POST RD
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CT
Mailing Address - Zip Code:06477-3545
Mailing Address - Country:US
Mailing Address - Phone:203-799-3343
Mailing Address - Fax:
Practice Address - Street 1:400 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CT
Practice Address - Zip Code:06477-3545
Practice Address - Country:US
Practice Address - Phone:203-799-3343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT14.011404225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist