Provider Demographics
NPI:1104374651
Name:ROERO, JACLYN MICHELLE BROOKE (OT)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:MICHELLE BROOKE
Last Name:ROERO
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1790 SW 43RD WAY
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33317-5701
Mailing Address - Country:US
Mailing Address - Phone:855-442-2454
Mailing Address - Fax:954-206-7699
Practice Address - Street 1:1790 SW 43RD WAY
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33317-5701
Practice Address - Country:US
Practice Address - Phone:855-442-2454
Practice Address - Fax:954-206-7699
Is Sole Proprietor?:No
Enumeration Date:2016-09-13
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT17693225XP0200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018832000Medicaid