Provider Demographics
NPI:1609385285
Name:SALEM, JACQULYNN
Entity Type:Individual
Prefix:
First Name:JACQULYNN
Middle Name:
Last Name:SALEM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 LEVI LN
Mailing Address - Street 2:
Mailing Address - City:ADAMS
Mailing Address - State:NE
Mailing Address - Zip Code:68301-8830
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 LEVI LN
Practice Address - Street 2:
Practice Address - City:ADAMS
Practice Address - State:NE
Practice Address - Zip Code:68301-8830
Practice Address - Country:US
Practice Address - Phone:402-988-7115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-26
Last Update Date:2017-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2161225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty