Provider Demographics
NPI:1386682557
Name:STANLEY, JACLYN BROOKE (MS, ATC)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:BROOKE
Last Name:STANLEY
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:914 SOUTHGATE DR
Mailing Address - Street 2:APT. 2
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16801-4391
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 REGENT CT
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-7965
Practice Address - Country:US
Practice Address - Phone:814-231-2101
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART002377A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer