Provider Demographics
NPI:1245668987
Name:FENTON, JACQLYN (DPT)
Entity type:Individual
Prefix:
First Name:JACQLYN
Middle Name:
Last Name:FENTON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 S CLAREMONT ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-1451
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 S CLAREMONT ST
Practice Address - Street 2:SUITE 106
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-1451
Practice Address - Country:US
Practice Address - Phone:650-685-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-16
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA405612251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic