Provider Demographics
NPI:1902836711
Name:SEVERINI, JACQUELINE M (PT, MA)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:M
Last Name:SEVERINI
Suffix:
Gender:F
Credentials:PT, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1014
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066-1014
Mailing Address - Country:US
Mailing Address - Phone:973-855-9751
Mailing Address - Fax:973-855-9755
Practice Address - Street 1:2625 MORRIS AVE
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-5606
Practice Address - Country:US
Practice Address - Phone:908-686-0840
Practice Address - Fax:732-855-9755
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00638300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ058855 DBDMedicare ID - Type Unspecified