Provider Demographics
NPI:1669842100
Name:PETUYA, JACLYN WOOTERS (DPT)
Entity Type:Individual
Prefix:MRS
First Name:JACLYN
Middle Name:WOOTERS
Last Name:PETUYA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:DR
Other - First Name:JACLYN
Other - Middle Name:WOOTERS
Other - Last Name:PETUYA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPT
Mailing Address - Street 1:23 FOREST CREEK DR
Mailing Address - Street 2:
Mailing Address - City:HOCKESSIN
Mailing Address - State:DE
Mailing Address - Zip Code:19707-2017
Mailing Address - Country:US
Mailing Address - Phone:302-540-7006
Mailing Address - Fax:
Practice Address - Street 1:23 FOREST CREEK DR
Practice Address - Street 2:
Practice Address - City:HOCKESSIN
Practice Address - State:DE
Practice Address - Zip Code:19707-2017
Practice Address - Country:US
Practice Address - Phone:302-540-7006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-27
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ1-0003076225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist