Basic Information
Provider Information | |||||||||
NPI: | 1811311269 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JANKINS | ||||||||
FirstName: | REBECCA | ||||||||
MiddleName: | R | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPT, PT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DION | ||||||||
OtherFirstName: | REBECCA | ||||||||
OtherMiddleName: | R | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DPT | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1 CREDIT UNION WAY FL 3 | ||||||||
Address2: |   | ||||||||
City: | RANDOLPH | ||||||||
State: | MA | ||||||||
PostalCode: | 023684633 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7819613370 | ||||||||
FaxNumber: | 7819611291 | ||||||||
Practice Location | |||||||||
Address1: | 445 CENTRAL ST | ||||||||
Address2: |   | ||||||||
City: | STOUGHTON | ||||||||
State: | MA | ||||||||
PostalCode: | 020721900 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7813411942 | ||||||||
FaxNumber: | 7814368554 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/05/2014 | ||||||||
LastUpdateDate: | 04/03/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 20589 | MA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 110101616A | 05 | MA |   | MEDICAID | 4801609 | 01 | MA | AETNA | OTHER | 051892 | 01 | MA | UHC-OPTUM | OTHER |