Provider Demographics
NPI:1902121619
Name:FAULK, JACQUELINE (COTA)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:
Last Name:FAULK
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 STERLING PL APT 3B
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11233-4520
Mailing Address - Country:US
Mailing Address - Phone:347-683-9956
Mailing Address - Fax:
Practice Address - Street 1:4802 10TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-2916
Practice Address - Country:US
Practice Address - Phone:718-283-6418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-06
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant