Provider Demographics
NPI:1942678719
Name:HENRY, JACLYN A
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:A
Last Name:HENRY
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 1:129 N WASHINGTON AVE
Mailing Address - Street 2:APT 611
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18503-2201
Mailing Address - Country:US
Mailing Address - Phone:570-956-1855
Mailing Address - Fax:
Practice Address - Street 1:440 N RIVER ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-2631
Practice Address - Country:US
Practice Address - Phone:570-825-5611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-09
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT024490225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist