Provider Demographics
NPI:1649579137
Name:ELDRIDGE, JACLYN PROVAU (OTR/L)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:PROVAU
Last Name:ELDRIDGE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 DUNLOP FARMS BLVD
Mailing Address - Street 2:
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-1792
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:235 DUNLOP FARMS BLVD
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-1792
Practice Address - Country:US
Practice Address - Phone:804-520-0050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-23
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119005302225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist