Provider Demographics
NPI:1841553641
Name:EXLEY, JACQUELINE R (DPT)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:R
Last Name:EXLEY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MS
Other - First Name:JACQUELINE
Other - Middle Name:R
Other - Last Name:BACCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:902 WEST ERIE PLAZA DR.
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-4536
Mailing Address - Country:US
Mailing Address - Phone:814-456-6000
Mailing Address - Fax:814-456-6060
Practice Address - Street 1:902 WEST ERIE PLAZA DR.
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16505-4536
Practice Address - Country:US
Practice Address - Phone:814-456-6000
Practice Address - Fax:814-456-6060
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
PAPT022060225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA002708901OtherBS
PA1027700880001Medicaid
PA1027700880001Medicaid