MEDICARE: JACQUELYNN ELLIOTT LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	011719-1	NY

General Provider Information

NPI Number	:	1366910226
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELYNN ELLIOTT LMT

Provider Business Mailing Address
First Line	:	32 WERGER RD
Second Line	:
City	:	WEST SAND LAKE
State	:	NY
Zip	:	12196-2013
Country	:	US
Telephone Number	:	518-424-9580
Fax Number	:

Provider Business Practice Location Address
First Line	:	32 WERGER RD
Second Line	:
City	:	WEST SAND LAKE
State	:	NY
Zip	:	12196-2013
Country	:	US
Telephone Number	:	518-424-9580
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2018
Last Update Date	:	11/08/2018

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