Provider Demographics
NPI:1477203818
Name:SHEEHAN, JACLYN CRYSTAL (PTA)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:CRYSTAL
Last Name:SHEEHAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:CRYSTAL
Other - Last Name:ELMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:1256 MINHINETTE DR
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-3663
Mailing Address - Country:US
Mailing Address - Phone:404-734-9628
Mailing Address - Fax:
Practice Address - Street 1:25 GLENLAKE PKWY
Practice Address - Street 2:
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30328-3403
Practice Address - Country:US
Practice Address - Phone:678-619-0418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-28
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA03776225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant