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General NPI Number Information
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NPI Number | 1346822426
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Entity Type | Individual
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Provider Name | JACLYN MCCULLOUGH PT, DPT
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Gender | Female
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Dates
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Enumeration Date | 04/27/2021
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Last Update Date | 03/08/2023
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Provider Practice Location Address
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Address Line | 1128 NY-17K SUITE 3
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City | MONTGOMERY
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State | NY
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Zip | 12549-1254
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Country | US
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Telephone | 845-769-7777
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Fax | 845-769-0007
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Provider Business Mailing Address
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Address Line | 1128 STATE ROUTE 17K STE 3
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City | MONTGOMERY
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State | NY
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Zip | 12549-2270
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Country | US
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Telephone | 845-769-7777
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Fax | 845-769-0007
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | P20288
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License Number State | NC
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