1063586964 NPI number — JACKIE LYN DAVIS PT

Table of content: JACKIE LYN DAVIS PT (NPI 1063586964)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063586964 NPI number — JACKIE LYN DAVIS PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIS
Provider First Name:
JACKIE
Provider Middle Name:
LYN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
YUNKER
Provider Other First Name:
JACKIE
Provider Other Middle Name:
LYN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1063586964
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2416 CONSTITUTION AVENUE
Provider Second Line Business Mailing Address:
REHABILITATION TODAY
Provider Business Mailing Address City Name:
OLEAN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14760
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-372-2808
Provider Business Mailing Address Fax Number:
716-372-2902

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2416 CONSTITUTION AVENUE
Provider Second Line Business Practice Location Address:
REHABILITATION TODAY
Provider Business Practice Location Address City Name:
OLEAN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14760
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-372-2808
Provider Business Practice Location Address Fax Number:
716-372-2902
Provider Enumeration Date:
11/20/2006

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: 225100000X , with the licence number:  0218191 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225100000X , with the licence number: PT014053L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 000626459001 . This is a "BCBS WNY" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 6697122 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00011264701 . This is a "UNIVECA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".