Provider Demographics
NPI:1457840621
Name:EVANS, JACLYN (OTR/L)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:EVANS
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 1:206 COUNTY ROAD 754
Mailing Address - Street 2:
Mailing Address - City:RICEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37370-5260
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:875 W MCKINLEY AVE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-3287
Practice Address - Country:US
Practice Address - Phone:217-872-1282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-03
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4925225X00000X
IL056015359225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist