Provider Demographics
NPI:1477797389
Name:BLADY, JACLYN (PT)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:BLADY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 YORKSHIRE WAY
Mailing Address - Street 2:
Mailing Address - City:HATBORO
Mailing Address - State:PA
Mailing Address - Zip Code:19040-2110
Mailing Address - Country:US
Mailing Address - Phone:215-962-8872
Mailing Address - Fax:
Practice Address - Street 1:3075 RIDGE PIKE
Practice Address - Street 2:
Practice Address - City:EAGLEVILLE
Practice Address - State:PA
Practice Address - Zip Code:19403
Practice Address - Country:US
Practice Address - Phone:215-962-8872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-22
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT0166912251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100980602OtherMA NUMBER