Provider Demographics
NPI:1972248128
Name:NICODEMO, JACLYN MARIE (LMT)
Entity Type:Individual
Prefix:MS
First Name:JACLYN
Middle Name:MARIE
Last Name:NICODEMO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:MARIE
Other - Last Name:NICODEMO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:JACLYN TASSONI
Mailing Address - Street 1:343 ROSS RD
Mailing Address - Street 2:
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-2108
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:970 PULASKI DR
Practice Address - Street 2:
Practice Address - City:KING OF PRUSSIA
Practice Address - State:PA
Practice Address - Zip Code:19406-2802
Practice Address - Country:US
Practice Address - Phone:610-640-9355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-02
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC009420111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty