Provider Demographics
NPI:1407458623
Name:KING, JACLYN (OTR/L)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W RIDGELY RD STE 8A
Mailing Address - Street 2:
Mailing Address - City:LUTHERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21093-5124
Mailing Address - Country:US
Mailing Address - Phone:443-367-1333
Mailing Address - Fax:
Practice Address - Street 1:101 W RIDGELY RD STE 8A
Practice Address - Street 2:
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-5124
Practice Address - Country:US
Practice Address - Phone:443-367-1333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-12
Last Update Date:2022-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD09091225X00000X
PAOC017199225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist