Healthcare Provider Details

I. General information

NPI: 1871807958
Provider Name (Legal Business Name): JENNIFER MARIE TATLOCK DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER MARIE BEATON DPT

II. Dates (important events)

Enumeration Date: 08/02/2010
Last Update Date: 08/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

178 CLIZBE AVE
AMSTERDAM NY
12010-2935
US

IV. Provider business mailing address

42 SARATOGA RD
SCOTIA NY
12302-3412
US

V. Phone/Fax

Practice location:
  • Phone: 518-842-1425
  • Fax: 518-842-1706
Mailing address:
  • Phone: 518-399-6861
  • Fax: 518-399-6864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number032826-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: