Provider Demographics
NPI:1063586964
Name:DAVIS, JACKIE LYN (PT)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:LYN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:LYN
Other - Last Name:YUNKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2416 CONSTITUTION AVENUE
Mailing Address - Street 2:REHABILITATION TODAY
Mailing Address - City:OLEAN
Mailing Address - State:NY
Mailing Address - Zip Code:14760
Mailing Address - Country:US
Mailing Address - Phone:716-372-2808
Mailing Address - Fax:716-372-2902
Practice Address - Street 1:2416 CONSTITUTION AVENUE
Practice Address - Street 2:REHABILITATION TODAY
Practice Address - City:OLEAN
Practice Address - State:NY
Practice Address - Zip Code:14760
Practice Address - Country:US
Practice Address - Phone:716-372-2808
Practice Address - Fax:716-372-2902
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0218191225100000X
PAPT014053L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000626459001OtherBCBS WNY
NY6697122OtherGHI
NY00011264701OtherUNIVECA
NYP34301Medicare UPIN
PA085969Medicare ID - Type Unspecified
NYCC6678Medicare ID - Type Unspecified