Provider Demographics
NPI:1740678788
Name:KRIDER, JACQULYN (PTA)
Entity type:Individual
Prefix:
First Name:JACQULYN
Middle Name:
Last Name:KRIDER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37930 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:WOODSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:43793-9247
Mailing Address - Country:US
Mailing Address - Phone:740-472-9869
Mailing Address - Fax:740-472-1707
Practice Address - Street 1:37930 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:WOODSFIELD
Practice Address - State:OH
Practice Address - Zip Code:43793-9247
Practice Address - Country:US
Practice Address - Phone:740-472-9869
Practice Address - Fax:740-472-1707
Is Sole Proprietor?:No
Enumeration Date:2014-12-29
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6188225200000X
OH20299225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist