Healthcare Provider Details

I. General information

NPI: 1679492136
Provider Name (Legal Business Name): JACQUELINE FABIOLA PAINCHAUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1715 ELLINGTON RD
SOUTH WINDSOR CT
06074-2707
US

IV. Provider business mailing address

108 BEACH DR
PROSPECT CT
06712-1603
US

V. Phone/Fax

Practice location:
  • Phone: 860-783-7923
  • Fax:
Mailing address:
  • Phone: 207-841-3646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2560
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPA70000061
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: