Provider Demographics
NPI:1669829347
Name:CLAUSON, JACLYN (MM, ATC, LAT)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:CLAUSON
Suffix:
Gender:F
Credentials:MM, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4828 COLONY CHURCH RD APT 10
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63129-1169
Mailing Address - Country:US
Mailing Address - Phone:320-226-4377
Mailing Address - Fax:
Practice Address - Street 1:2800 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-6612
Practice Address - Country:US
Practice Address - Phone:320-226-4377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-23
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20140272932255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer