Provider Demographics
NPI:1417206871
Name:REAVES, JACQUELYN FAYE (OTR)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:FAYE
Last Name:REAVES
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6105 NORWICH CT
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73132-2604
Mailing Address - Country:US
Mailing Address - Phone:405-210-6049
Mailing Address - Fax:
Practice Address - Street 1:6525 N MERIDIAN AVE
Practice Address - Street 2:SUITE 311
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-1420
Practice Address - Country:US
Practice Address - Phone:405-721-1115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-31
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK338225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist