Provider Demographics
NPI:1003187451
Name:CLEMONS, JACQULINE (LOTR)
Entity type:Individual
Prefix:MS
First Name:JACQULINE
Middle Name:
Last Name:CLEMONS
Suffix:
Gender:F
Credentials:LOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5543 FRANCES CT
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27105-1772
Mailing Address - Country:US
Mailing Address - Phone:336-624-3454
Mailing Address - Fax:336-744-5624
Practice Address - Street 1:625 ASHLAND ST
Practice Address - Street 2:
Practice Address - City:ARCHDALE
Practice Address - State:NC
Practice Address - Zip Code:27263-2943
Practice Address - Country:US
Practice Address - Phone:336-434-2902
Practice Address - Fax:336-434-4477
Is Sole Proprietor?:No
Enumeration Date:2012-01-17
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5927225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist