Provider Demographics
NPI:1770831448
Name:PACETTI, JACLYN MICHELLE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:JACLYN
Middle Name:MICHELLE
Last Name:PACETTI
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:JACLYN
Other - Middle Name:MICHELLE
Other - Last Name:VASQUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:6405 NW 36TH ST
Mailing Address - Street 2:SUITE #105
Mailing Address - City:VIRGINIA GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33166-6974
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6405 NW 36TH ST
Practice Address - Street 2:SUITE #105
Practice Address - City:VIRGINIA GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33166-6974
Practice Address - Country:US
Practice Address - Phone:305-856-1999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-28
Last Update Date:2013-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA23491225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant