Provider Demographics
NPI:1790449650
Name:POVILAITIS, JACQUELYN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:POVILAITIS
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 1:7810 N US HIGHWAY 89 STE 270-280
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-6255
Mailing Address - Country:US
Mailing Address - Phone:928-522-8375
Mailing Address - Fax:
Practice Address - Street 1:7810 N US HIGHWAY 89 STE 270-280
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-6255
Practice Address - Country:US
Practice Address - Phone:928-522-8375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-27
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ012236225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist