Provider Demographics
NPI:1174760755
Name:BRUNELL, JACQUELINE ASHLEY (PT, DPT)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:ASHLEY
Last Name:BRUNELL
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3506 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:SHRUB OAK
Mailing Address - State:NY
Mailing Address - Zip Code:10588-1916
Mailing Address - Country:US
Mailing Address - Phone:631-241-2727
Mailing Address - Fax:
Practice Address - Street 1:3506 JAMES ST
Practice Address - Street 2:
Practice Address - City:SHRUB OAK
Practice Address - State:NY
Practice Address - Zip Code:10588-1916
Practice Address - Country:US
Practice Address - Phone:631-241-2727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-19
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031023-12251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics