Provider Demographics
NPI:1104499433
Name:KUHN PROVENZANO, JACQUELYN (MOT)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:KUHN PROVENZANO
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 416495
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-6495
Mailing Address - Country:US
Mailing Address - Phone:631-580-5200
Mailing Address - Fax:631-580-5222
Practice Address - Street 1:579 CRANBURY RD STE C
Practice Address - Street 2:
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-5405
Practice Address - Country:US
Practice Address - Phone:732-432-0733
Practice Address - Fax:732-432-9131
Is Sole Proprietor?:No
Enumeration Date:2021-07-23
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00610600225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist