Provider Demographics
NPI:1669085767
Name:CARRANZA, JACLYN DEANE
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:DEANE
Last Name:CARRANZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:KS
Mailing Address - Zip Code:67156-2499
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:KS
Practice Address - Zip Code:67156-2499
Practice Address - Country:US
Practice Address - Phone:620-229-6159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer