Provider Demographics
NPI:1134750482
Name:CRUSH, JACLYN ANNE (PT, DPT, WCS)
Entity type:Individual
Prefix:DR
First Name:JACLYN
Middle Name:ANNE
Last Name:CRUSH
Suffix:
Gender:F
Credentials:PT, DPT, WCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6801 NORTHWIND WAY
Mailing Address - Street 2:
Mailing Address - City:CRESTWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:40014-7783
Mailing Address - Country:US
Mailing Address - Phone:502-648-9624
Mailing Address - Fax:
Practice Address - Street 1:6801 NORTHWIND WAY
Practice Address - Street 2:
Practice Address - City:CRESTWOOD
Practice Address - State:KY
Practice Address - Zip Code:40014-7783
Practice Address - Country:US
Practice Address - Phone:502-648-9624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-27
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPT-007892225100000X
GAPT014708225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty