1861630972 NPI number — MRS. JENNIFER ANN FACKELMAN OTR

Table of content: MRS. JENNIFER ANN FACKELMAN OTR (NPI 1861630972)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861630972 NPI number — MRS. JENNIFER ANN FACKELMAN OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FACKELMAN
Provider First Name:
JENNIFER
Provider Middle Name:
ANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OTR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BURNISKY
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTR
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1861630972
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/27/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
42 NORBROOK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAIRPORT
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14450-8958
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-797-9366
Provider Business Mailing Address Fax Number:
585-486-1230

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
42 NORBROOK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRPORT
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14450-8958
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-797-9366
Provider Business Practice Location Address Fax Number:
585-486-1230
Provider Enumeration Date:
01/27/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225XP0200X , with the licence number:  008637-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com