Provider Demographics
NPI:1972871150
Name:RUPERT, JACLYN (COTA)
Entity type:Individual
Prefix:MISS
First Name:JACLYN
Middle Name:
Last Name:RUPERT
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 PLEASANT AVE
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14075
Mailing Address - Country:US
Mailing Address - Phone:716-430-5614
Mailing Address - Fax:
Practice Address - Street 1:150 PLEASANT AVE
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:NY
Practice Address - Zip Code:14075-4828
Practice Address - Country:US
Practice Address - Phone:716-430-5614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-02
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
004818-01174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY166001780Medicaid