Provider Demographics
NPI:1184850083
Name:WALSH, JACLYN ELIZABETH (DC)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:ELIZABETH
Last Name:WALSH
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1456 PERIWINKLE WAY
Mailing Address - Street 2:SUITE C
Mailing Address - City:SANIBEL
Mailing Address - State:FL
Mailing Address - Zip Code:33957-4512
Mailing Address - Country:US
Mailing Address - Phone:270-519-5665
Mailing Address - Fax:
Practice Address - Street 1:1456 PERIWINKLE WAY
Practice Address - Street 2:SUITE C
Practice Address - City:SANIBEL
Practice Address - State:FL
Practice Address - Zip Code:33957-4512
Practice Address - Country:US
Practice Address - Phone:270-519-5665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-05
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5187111N00000X
FLCH 10671111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor