Provider Demographics
NPI:1699768861
Name:FEHRENBACK, JACLYN V (DPT)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:V
Last Name:FEHRENBACK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 BOYLSTON ST
Mailing Address - Street 2:APT 25G
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02199-7700
Mailing Address - Country:US
Mailing Address - Phone:973-224-3792
Mailing Address - Fax:
Practice Address - Street 1:770 BOYLSTON ST
Practice Address - Street 2:APT 25G
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02199-7700
Practice Address - Country:US
Practice Address - Phone:973-224-3792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT016320225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA073094Medicare ID - Type Unspecified