Provider Demographics
NPI:1871807958
Name:TATLOCK, JENNIFER MARIE (DPT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:TATLOCK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:MARIE
Other - Last Name:BEATON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:42 SARATOGA RD
Mailing Address - Street 2:
Mailing Address - City:SCOTIA
Mailing Address - State:NY
Mailing Address - Zip Code:12302-3412
Mailing Address - Country:US
Mailing Address - Phone:518-399-6861
Mailing Address - Fax:518-399-6864
Practice Address - Street 1:178 CLIZBE AVE
Practice Address - Street 2:
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010-2935
Practice Address - Country:US
Practice Address - Phone:518-842-1425
Practice Address - Fax:518-842-1706
Is Sole Proprietor?:No
Enumeration Date:2010-08-02
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032826-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03005754Medicaid
NYJ400084073Medicare PIN