Provider Demographics
NPI:1396220851
Name:KNOWLDEN, JACLYN KAY
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:KAY
Last Name:KNOWLDEN
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 1:306 BOYD LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28387-7302
Mailing Address - Country:US
Mailing Address - Phone:303-319-2242
Mailing Address - Fax:
Practice Address - Street 1:300 BLAKE BLVD
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-8474
Practice Address - Country:US
Practice Address - Phone:910-295-6158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-01
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6733225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant