Provider Demographics
NPI:1013160837
Name:JACKSON-DOEBLER, KELLY CHRISTINE (PT)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:CHRISTINE
Last Name:JACKSON-DOEBLER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:CHRISTINE
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:6 JOHNSTON ST
Mailing Address - Street 2:
Mailing Address - City:SENECA FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:13148-1206
Mailing Address - Country:US
Mailing Address - Phone:315-568-2476
Mailing Address - Fax:315-568-8958
Practice Address - Street 1:6 JOHNSTON ST
Practice Address - Street 2:
Practice Address - City:SENECA FALLS
Practice Address - State:NY
Practice Address - Zip Code:13148-1206
Practice Address - Country:US
Practice Address - Phone:315-568-2476
Practice Address - Fax:315-568-8958
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-23
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012059-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist