Provider Demographics
NPI:1922616374
Name:PASTENA, JACLYN (OTR/L)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:PASTENA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:20588 S ELLSWORTH LOOP RD APT 3125
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-0146
Mailing Address - Country:US
Mailing Address - Phone:602-341-3770
Mailing Address - Fax:602-560-0504
Practice Address - Street 1:20588 S ELLSWORTH LOOP RD APT 3125
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85142-0146
Practice Address - Country:US
Practice Address - Phone:602-341-3770
Practice Address - Fax:602-560-0504
Is Sole Proprietor?:No
Enumeration Date:2020-07-21
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTH-009411225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1707637Medicaid