Provider Demographics
NPI:1124198213
Name:SPRACKLEN, JAY LAWRENCE (PT)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:LAWRENCE
Last Name:SPRACKLEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2845 S 70TH ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506
Mailing Address - Country:US
Mailing Address - Phone:402-489-1999
Mailing Address - Fax:402-489-4153
Practice Address - Street 1:2845 S 70TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506
Practice Address - Country:US
Practice Address - Phone:402-489-1999
Practice Address - Fax:402-489-4153
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1233225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE76058051000Medicaid
NE1124198213Medicare PIN