Provider Demographics
NPI:1487180790
Name:VOOGE, JACLYN (OTR/L)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:VOOGE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1406 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-3239
Mailing Address - Country:US
Mailing Address - Phone:307-463-0462
Mailing Address - Fax:307-463-2010
Practice Address - Street 1:603 E CARLSON ST STE 304
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-4443
Practice Address - Country:US
Practice Address - Phone:307-514-9999
Practice Address - Fax:307-514-6006
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-05
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYOT-1447225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY154258300Medicaid