Provider Demographics
NPI:1295920726
Name:ANDERSON, JACLYN MARIE (OT)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:MARIE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2830 S PINE MEADOW PATH
Mailing Address - Street 2:
Mailing Address - City:SUTTONS BAY
Mailing Address - State:MI
Mailing Address - Zip Code:49682-9740
Mailing Address - Country:US
Mailing Address - Phone:231-218-2302
Mailing Address - Fax:231-271-1214
Practice Address - Street 1:124 W FOURTH ST
Practice Address - Street 2:
Practice Address - City:SUTTONS BAY
Practice Address - State:MI
Practice Address - Zip Code:49682-9733
Practice Address - Country:US
Practice Address - Phone:231-271-1200
Practice Address - Fax:231-271-1214
Is Sole Proprietor?:No
Enumeration Date:2007-09-07
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201005612225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI43-2035142OtherTAX ID