Provider Demographics
NPI:1871250738
Name:FITZPATRICK, JACLYN
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:FITZPATRICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01887-3354
Mailing Address - Country:US
Mailing Address - Phone:781-475-9929
Mailing Address - Fax:
Practice Address - Street 1:IRONSTONE FARM, 450 LOWELL ST
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810
Practice Address - Country:US
Practice Address - Phone:978-475-4056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-26
Last Update Date:2021-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3890224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant