Provider Demographics
NPI:1477833176
Name:DAVIS, JACLYN MICHELLE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACLYN
Middle Name:MICHELLE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MS
Other - First Name:JACLYN
Other - Middle Name:MICHELLE
Other - Last Name:STADT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1045 S CEDAR CREST BLVD
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-5443
Mailing Address - Country:US
Mailing Address - Phone:610-433-3360
Mailing Address - Fax:
Practice Address - Street 1:1515 S CAPITAL OF TEXAS HWY STE 200
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78746-6544
Practice Address - Country:US
Practice Address - Phone:512-649-1742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-25
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38202103TC0700X
PAPS017996103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA472922Medicare PIN