Provider Demographics
NPI:1225583578
Name:WICKER, JACLYN NICOL (OTR)
Entity Type:Individual
Prefix:MRS
First Name:JACLYN
Middle Name:NICOL
Last Name:WICKER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5904 SUMMERFIELD DR
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-4306
Mailing Address - Country:US
Mailing Address - Phone:903-793-6135
Mailing Address - Fax:903-793-0053
Practice Address - Street 1:5904 SUMMERFIELD DR
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-4306
Practice Address - Country:US
Practice Address - Phone:903-793-6135
Practice Address - Fax:903-793-0053
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-16
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX117143225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist