Provider Demographics
NPI:1598215055
Name:MATHIS, JACLENE (COTA/L)
Entity Type:Individual
Prefix:
First Name:JACLENE
Middle Name:
Last Name:MATHIS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:524 PLEASANT SIDE DR
Mailing Address - Street 2:
Mailing Address - City:MONCKS CORNER
Mailing Address - State:SC
Mailing Address - Zip Code:29461-7387
Mailing Address - Country:US
Mailing Address - Phone:843-568-2932
Mailing Address - Fax:
Practice Address - Street 1:524 PLEASANT SIDE DR
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-7387
Practice Address - Country:US
Practice Address - Phone:843-568-2932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-09
Last Update Date:2016-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3060224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant