Provider Demographics
NPI:1295167369
Name:PACHUTA, JACLYN M (AT)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:M
Last Name:PACHUTA
Suffix:
Gender:F
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1475 EDGEWOOD DR
Mailing Address - Street 2:APT. I-8
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-1057
Mailing Address - Country:US
Mailing Address - Phone:614-578-1276
Mailing Address - Fax:
Practice Address - Street 1:1475 EDGEWOOD DR
Practice Address - Street 2:APT. I-8
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45805-1057
Practice Address - Country:US
Practice Address - Phone:614-578-1276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-31
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0035062255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer