Provider Demographics
NPI:1811362171
Name:HUMBARD, JACKLYN (PTA)
Entity Type:Individual
Prefix:
First Name:JACKLYN
Middle Name:
Last Name:HUMBARD
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6501 HARDING PIKE APT P11
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37205-4020
Mailing Address - Country:US
Mailing Address - Phone:815-245-2988
Mailing Address - Fax:
Practice Address - Street 1:1211 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37232-0004
Practice Address - Country:US
Practice Address - Phone:615-343-9055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-11
Last Update Date:2015-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6140208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation