Provider Demographics
NPI:1225319031
Name:RICHARD, JACLYN
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:RICHARD
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 1:3001 E LAKE DR
Mailing Address - Street 2:B2221
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89177-0001
Mailing Address - Country:US
Mailing Address - Phone:702-742-8868
Mailing Address - Fax:
Practice Address - Street 1:3001 E LAKE DR
Practice Address - Street 2:B2221
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89177-0001
Practice Address - Country:US
Practice Address - Phone:702-742-8868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-07
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner