Provider Demographics
NPI:1306117270
Name:SWENSON, JACQUELINE J (MSPT)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:J
Last Name:SWENSON
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 BITTERSWEET LN
Mailing Address - Street 2:
Mailing Address - City:SLINGERLANDS
Mailing Address - State:NY
Mailing Address - Zip Code:12159-9424
Mailing Address - Country:US
Mailing Address - Phone:518-212-7515
Mailing Address - Fax:
Practice Address - Street 1:22 BITTERSWEET LN
Practice Address - Street 2:
Practice Address - City:SLINGERLANDS
Practice Address - State:NY
Practice Address - Zip Code:12159-9424
Practice Address - Country:US
Practice Address - Phone:518-212-7515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-24
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031606225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1306117270Medicaid