Provider Demographics
NPI:1710595533
Name:KERR, JACLYN (COTA/L)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:KERR
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 DIANA PL
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-2656
Mailing Address - Country:US
Mailing Address - Phone:714-488-9099
Mailing Address - Fax:
Practice Address - Street 1:1700 12TH ST STE C
Practice Address - Street 2:
Practice Address - City:HOOD RIVER
Practice Address - State:OR
Practice Address - Zip Code:97031-9005
Practice Address - Country:US
Practice Address - Phone:541-716-1316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-17
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4501224Z00000X
OR404231224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant