Provider Demographics
NPI:1164935367
Name:BASCOMB-HARRISON, JACKLYN SUE (MS, ATC)
Entity Type:Individual
Prefix:
First Name:JACKLYN
Middle Name:SUE
Last Name:BASCOMB-HARRISON
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:JACKLYN
Other - Middle Name:SUE
Other - Last Name:BASCOMB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, ATC
Mailing Address - Street 1:984 RICE DR
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77803-1867
Mailing Address - Country:US
Mailing Address - Phone:970-301-7183
Mailing Address - Fax:
Practice Address - Street 1:400 BIZZELL ST
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77843-0002
Practice Address - Country:US
Practice Address - Phone:979-458-0257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-09
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer