Provider Demographics
NPI:1043361280
Name:HOSTETLER, JACQUELINE C (OTRL)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:C
Last Name:HOSTETLER
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 NICKLAUS DR NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-9518
Mailing Address - Country:US
Mailing Address - Phone:706-346-4666
Mailing Address - Fax:706-232-9303
Practice Address - Street 1:30 NICKLAUS DR NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-9518
Practice Address - Country:US
Practice Address - Phone:706-346-4666
Practice Address - Fax:706-232-9303
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT004490225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA777866008CMedicaid