Provider Demographics
NPI:1114490786
Name:REESE, JACLYN ROSE
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:ROSE
Last Name:REESE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5028 ORVAS CT SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-4765
Mailing Address - Country:US
Mailing Address - Phone:360-918-6057
Mailing Address - Fax:
Practice Address - Street 1:1301 N HIGHLANDS PKWY
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98406-2116
Practice Address - Country:US
Practice Address - Phone:253-752-7112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-07
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT.OT.60920648225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist