Provider Demographics
NPI:1700812070
Name:TE, JACQUELYN TATING (PT)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:TATING
Last Name:TE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 FORGE CROSSING CT
Mailing Address - Street 2:
Mailing Address - City:PERRY HALL
Mailing Address - State:MD
Mailing Address - Zip Code:21128-8833
Mailing Address - Country:US
Mailing Address - Phone:646-541-1198
Mailing Address - Fax:
Practice Address - Street 1:5009 HONEYGO CENTER DR STE 209
Practice Address - Street 2:
Practice Address - City:PERRY HALL
Practice Address - State:MD
Practice Address - Zip Code:21128-9842
Practice Address - Country:US
Practice Address - Phone:443-725-2150
Practice Address - Fax:443-725-2155
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD24357225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
065140BMPMedicare ID - Type Unspecified