Provider Demographics
NPI:1720313273
Name:BORMANN, JACLYN MARIE (LPT)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:MARIE
Last Name:BORMANN
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:MARIE
Other - Last Name:OLDHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:850 43RD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-8401
Mailing Address - Country:US
Mailing Address - Phone:309-743-2070
Mailing Address - Fax:
Practice Address - Street 1:111 HIGHWAY 150 N
Practice Address - Street 2:
Practice Address - City:WEST UNION
Practice Address - State:IA
Practice Address - Zip Code:52175-1050
Practice Address - Country:US
Practice Address - Phone:563-334-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-15
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA4058225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0665992Medicaid
IA0665992Medicaid