Provider Demographics
NPI:1609474584
Name:LOCKE, JACKLYN L (OTR/L)
Entity Type:Individual
Prefix:
First Name:JACKLYN
Middle Name:L
Last Name:LOCKE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:JACKLYN
Other - Middle Name:L
Other - Last Name:HOLMES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 48
Mailing Address - Street 2:
Mailing Address - City:CORNISH
Mailing Address - State:ME
Mailing Address - Zip Code:04020-0048
Mailing Address - Country:US
Mailing Address - Phone:207-256-7303
Mailing Address - Fax:
Practice Address - Street 1:16 OLD PIKE RD
Practice Address - Street 2:
Practice Address - City:CORNISH
Practice Address - State:ME
Practice Address - Zip Code:04020-3506
Practice Address - Country:US
Practice Address - Phone:207-625-4300
Practice Address - Fax:207-625-7300
Is Sole Proprietor?:No
Enumeration Date:2020-10-13
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT3892225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist