Provider Demographics
NPI:1497231476
Name:JACELON, MICHELLE LOUISE (PT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LOUISE
Last Name:JACELON
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 1:106 RAMBLING RD
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:TX
Mailing Address - Zip Code:75633-3282
Mailing Address - Country:US
Mailing Address - Phone:903-918-3308
Mailing Address - Fax:
Practice Address - Street 1:406 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:TX
Practice Address - Zip Code:75494-3226
Practice Address - Country:US
Practice Address - Phone:903-342-6790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1128429225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty