Provider Demographics
NPI:1598345506
Name:ROBISON, JACLYN JACI MIRANDA (OTR)
Entity Type:Individual
Prefix:
First Name:JACLYN JACI
Middle Name:MIRANDA
Last Name:ROBISON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:JACLYN JACI
Other - Middle Name:MIRANDA
Other - Last Name:NEWELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2000 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:LAKEWAY
Mailing Address - State:TX
Mailing Address - Zip Code:78734-4200
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2000 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78734-4200
Practice Address - Country:US
Practice Address - Phone:936-537-0123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-13
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX120177225XN1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation