Provider Demographics
NPI:1629706650
Name:BASSETT, MARY JACLYN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MARY JACLYN
Middle Name:
Last Name:BASSETT
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:383 WINDSWEPT WAY
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-3146
Mailing Address - Country:US
Mailing Address - Phone:904-302-3663
Mailing Address - Fax:
Practice Address - Street 1:1887 KINGSLEY AVE
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4416
Practice Address - Country:US
Practice Address - Phone:904-639-2715
Practice Address - Fax:904-639-7636
Is Sole Proprietor?:No
Enumeration Date:2022-08-09
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT26267225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist