Provider Demographics
NPI:1417269846
Name:VELASQUEZ, JACINTA (PTA)
Entity Type:Individual
Prefix:
First Name:JACINTA
Middle Name:
Last Name:VELASQUEZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1509 MARLOWE DR
Mailing Address - Street 2:A7
Mailing Address - City:CLARKSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47129-2069
Mailing Address - Country:US
Mailing Address - Phone:606-233-8270
Mailing Address - Fax:
Practice Address - Street 1:931 SOUTH THIRD STREET
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40203
Practice Address - Country:US
Practice Address - Phone:502-561-6431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-14
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA02561225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant