Provider Demographics
NPI:1841742012
Name:BRADY, JACLYN (DPT)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:BRADY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 E WHITTIER AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-5313
Mailing Address - Country:US
Mailing Address - Phone:937-878-3961
Mailing Address - Fax:937-879-8180
Practice Address - Street 1:306 E WHITTIER AVE
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-5313
Practice Address - Country:US
Practice Address - Phone:937-878-3961
Practice Address - Fax:937-879-8180
Is Sole Proprietor?:No
Enumeration Date:2016-11-03
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT0164012251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics