Provider Demographics
NPI:1265554620
Name:ALFONSI, JACQUELYN AVERY (COTA)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:AVERY
Last Name:ALFONSI
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 1:200 REDFORD RD
Mailing Address - Street 2:
Mailing Address - City:ORELAND
Mailing Address - State:PA
Mailing Address - Zip Code:19075-1926
Mailing Address - Country:US
Mailing Address - Phone:215-886-4815
Mailing Address - Fax:
Practice Address - Street 1:8833 STENTON AVE
Practice Address - Street 2:
Practice Address - City:WYNDMOOR
Practice Address - State:PA
Practice Address - Zip Code:19038-8319
Practice Address - Country:US
Practice Address - Phone:215-836-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP001877L224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant