Healthcare Provider Details

I. General information

NPI: 1750858965
Provider Name (Legal Business Name): JACLYN GAIL BUTENSKY MS, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2018
Last Update Date: 10/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15050 14TH RD
WHITESTONE NY
11357-2609
US

IV. Provider business mailing address

16 BRAYTON CT S
SOUTH SETAUKET NY
11720-4626
US

V. Phone/Fax

Practice location:
  • Phone: 718-767-0071
  • Fax:
Mailing address:
  • Phone: 631-880-1819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number023016
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: