Basic Information
| Provider Information | |||||||||
| NPI: | 1518413111 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAUKE | ||||||||
| FirstName: | JACLYNN | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| OtherLastName: | MALONEY | ||||||||
| OtherFirstName: | JACLYNN | ||||||||
| OtherMiddleName: | ANN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 938 | ||||||||
| Address2: | 54 MAIN STREET | ||||||||
| City: | STOCKBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 012620938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4132984401 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 151 CHRISTIAN HILL RD | ||||||||
| Address2: | |||||||||
| City: | GREAT BARRINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 012301108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135284560 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2016 | ||||||||
| LastUpdateDate: | 09/01/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 10974 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.