Provider Demographics
NPI:1902485626
Name:JAKUBOWSKI, STACEY EVELYN (OTR/L)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:EVELYN
Last Name:JAKUBOWSKI
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:EVELYN
Other - Last Name:MCMAHON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:5 CRESCENT RD
Mailing Address - Street 2:
Mailing Address - City:LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01106-1844
Mailing Address - Country:US
Mailing Address - Phone:617-688-6516
Mailing Address - Fax:
Practice Address - Street 1:5 CRESCENT RD
Practice Address - Street 2:
Practice Address - City:LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01106-1844
Practice Address - Country:US
Practice Address - Phone:617-688-6516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-08
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA12969225X00000X
CT48.005444225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist