Provider Demographics
NPI:1578161550
Name:CLOVER, JAQULYN (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:JAQULYN
Middle Name:
Last Name:CLOVER
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 DUNVEGAN DR
Mailing Address - Street 2:
Mailing Address - City:BELLA VISTA
Mailing Address - State:AR
Mailing Address - Zip Code:72715-4929
Mailing Address - Country:US
Mailing Address - Phone:870-926-6061
Mailing Address - Fax:
Practice Address - Street 1:6815 ISAACS ORCHARD RD STE D
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-6285
Practice Address - Country:US
Practice Address - Phone:479-856-6400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR3403225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist