Provider Demographics
NPI:1689120073
Name:PICCONE, JACLYN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:PICCONE
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 1:4555 BRENTWOOD ST
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-3242
Mailing Address - Country:US
Mailing Address - Phone:720-841-5835
Mailing Address - Fax:303-409-2233
Practice Address - Street 1:6612 S WARD ST
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80127-4855
Practice Address - Country:US
Practice Address - Phone:303-409-2133
Practice Address - Fax:303-409-2233
Is Sole Proprietor?:No
Enumeration Date:2016-08-26
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0014171225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPTL0014171OtherPT LICENSE