Provider Demographics
NPI:1376102640
Name:CLARKE, JACLYN
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:CLARKE
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 1:54 RICHMOND TOWNHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:RI
Mailing Address - Zip Code:02898-1228
Mailing Address - Country:US
Mailing Address - Phone:401-408-8485
Mailing Address - Fax:
Practice Address - Street 1:54 RICHMOND TOWNHOUSE RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:RI
Practice Address - Zip Code:02898-1228
Practice Address - Country:US
Practice Address - Phone:401-408-8485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMT02434225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist