Basic Information
| Provider Information | |||||||||
| NPI: | 1194238717 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | JACLYN | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 EVERGREEN AVE APT 8B | ||||||||
| Address2: | |||||||||
| City: | HAMDEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065182725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035062321 | ||||||||
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| Practice Location | |||||||||
| Address1: | 267 GRANT ST | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066102805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033843000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2017 | ||||||||
| LastUpdateDate: | 11/06/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XP0019X | 48.004771 | CT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Physical Rehabilitation |
No ID Information.