Provider Demographics
NPI:1679848667
Name:POLK, JACLYN ANN (DPT)
Entity Type:Individual
Prefix:MRS
First Name:JACLYN
Middle Name:ANN
Last Name:POLK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:ANN
Other - Last Name:REIFSCHNEIDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:5011 WEDDINGTON RD STE 50
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-9037
Mailing Address - Country:US
Mailing Address - Phone:980-248-1211
Mailing Address - Fax:703-471-0247
Practice Address - Street 1:5011 WEDDINGTON RD STE 50
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027-9037
Practice Address - Country:US
Practice Address - Phone:980-248-1211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-09
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305207809225100000X
DCPT871313225100000X
NCP18923225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1679848667OtherPHYSICAL THERAPY