Provider Demographics
NPI:1003571431
Name:OLDENBURG, JACLYN (MS, OT)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:OLDENBURG
Suffix:
Gender:F
Credentials:MS, OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 MAMARONECK AVE STE 140
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10605-5224
Mailing Address - Country:US
Mailing Address - Phone:914-294-4050
Mailing Address - Fax:631-760-8306
Practice Address - Street 1:16760 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-8864
Practice Address - Country:US
Practice Address - Phone:616-935-3300
Practice Address - Fax:616-935-3333
Is Sole Proprietor?:No
Enumeration Date:2021-11-01
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201011646225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist