Provider Demographics
NPI:1346765500
Name:PENNINGTON, JACLYN (CCLS)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:PENNINGTON
Suffix:
Gender:F
Credentials:CCLS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 LATHAM DR
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:AR
Mailing Address - Zip Code:72745-8360
Mailing Address - Country:US
Mailing Address - Phone:479-750-0130
Mailing Address - Fax:
Practice Address - Street 1:519 LATHAM DR
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:AR
Practice Address - Zip Code:72745-8360
Practice Address - Country:US
Practice Address - Phone:479-750-0130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-09
Last Update Date:2017-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist