Provider Demographics
NPI:1427353010
Name:GAULD, JENNIFER LOUISE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LOUISE
Last Name:GAULD
Suffix:
Gender:F
Credentials:
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 308
Mailing Address - Street 2:
Mailing Address - City:CORFU
Mailing Address - State:NY
Mailing Address - Zip Code:14036-0308
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8750 ALLEGHANY RD
Practice Address - Street 2:
Practice Address - City:CORFU
Practice Address - State:NY
Practice Address - Zip Code:14036-9702
Practice Address - Country:US
Practice Address - Phone:585-762-8713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-13
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013030-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist