Provider Demographics
NPI:1801980032
Name:JOHNSON, JACQUELINE M (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MISS
Other - First Name:JACQUELINE
Other - Middle Name:M
Other - Last Name:JORGENSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:71 LYELL AVE
Mailing Address - Street 2:
Mailing Address - City:SPENCERPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14559-1825
Mailing Address - Country:US
Mailing Address - Phone:585-349-5140
Mailing Address - Fax:
Practice Address - Street 1:71 LYELL AVE
Practice Address - Street 2:
Practice Address - City:SPENCERPORT
Practice Address - State:NY
Practice Address - Zip Code:14559-1825
Practice Address - Country:US
Practice Address - Phone:585-349-5140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY63 013501225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY30-0213081OtherTAX ID