Provider Demographics
NPI:1801625520
Name:WACKOWSKI, JENNA MICHELLE (OT)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:MICHELLE
Last Name:WACKOWSKI
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14203-1536
Mailing Address - Country:US
Mailing Address - Phone:716-854-5700
Mailing Address - Fax:716-854-5800
Practice Address - Street 1:700 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1536
Practice Address - Country:US
Practice Address - Phone:716-854-5700
Practice Address - Fax:716-854-5800
Is Sole Proprietor?:No
Enumeration Date:2024-07-31
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3001940225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist