Basic Information
| Provider Information | |||||||||
| NPI: | 1932391497 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENSLEY | ||||||||
| FirstName: | JACLYN | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4242 RIDGE LEA RD | ||||||||
| Address2: | |||||||||
| City: | AMHERST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142261051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168192400 | ||||||||
| FaxNumber: | 7168192419 | ||||||||
| Practice Location | |||||||||
| Address1: | 4242 RIDGE LEA RD | ||||||||
| Address2: | |||||||||
| City: | AMHERST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142261051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168192400 | ||||||||
| FaxNumber: | 7168192419 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2007 | ||||||||
| LastUpdateDate: | 04/25/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 027523-1 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 02888255 | 05 | NY | MEDICAID |