Provider Demographics
NPI:1952048407
Name:IAFRATE, JACLYN PASEK (PTA)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:PASEK
Last Name:IAFRATE
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 1:129 BARCLAY DR
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-0065
Mailing Address - Country:US
Mailing Address - Phone:704-606-0184
Mailing Address - Fax:
Practice Address - Street 1:4123 KUYKENDALL RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28270-4449
Practice Address - Country:US
Practice Address - Phone:704-708-9931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-17
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA3482225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant